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

Introduction

The early years of life have a profound impact on an individual’s long-term health and wellbeing. Children’s emotional, cognitive, linguistic, social and physical development, including the bond they form with parents, can significantly affect their future health and wellbeing as adults^1,2. Investing in early years therefore creates opportunities for the future². In Scotland, health visitors are well placed to contribute to improving the health and wellbeing of children. However, while a universal health visiting service has been in place in Scotland for over a century, service delivery has varied substantially in terms of assessment, resources and visiting patterns across and even within Health Boards in Scotland.

The Universal Health Visiting Pathway (UHVP)

In 2013, the Chief Nursing Officer for Scotland³, directed all Health Boards to enhance the role of health visitors in line with the Nursing for Health Review⁴ and the national Getting it Right For Every Child (GIRFEC) approach⁵. This resulted in the development of, an evidence review⁶ to support the delivery of an enhanced health visiting service. The evidence review examined the direct impact of the health visiting role and resulted in a redefined focus for Health Visiting that would focus on children aged 0-5 years (pre-school). The review also highlighted a need for consistency and efficient and effective use of resources within the service⁶. The evidence review was also clear that all pregnant women should receive an antenatal contact, to ensure a smoother transition of care from the midwife to health visitor post birth.

The UHVP was developed and refocuses the specialist role of health visitors towards the delivery of preventative and targeted interventions. The pathway is designed to be delivered by a health visitor workforce who are better equipped to address the specific needs of children and families. In relation to workforce, a caseload weighting tool was developed. This uses formula to calculate the core numbers of health visitors required in a Health Board area to meet wider population need and uses the Scottish Index of Multiple Deprivation (SIMD) in its calculations. This tool was developed to facilitate the effective allocation of resources to areas of greatest need. The tool acknowledges the role and responsibilities of health visitors and takes into account the additional home visits that form part of the UHVP. The tool was designed to ensure that the right numbers of health visitors are available to respond to the needs of children and families in Scotland. It also provides guidance around caseload size related to deprivation and complexity. This tool, along with other workforce planning tools, supports Health Boards in their overall workforce planning, in managing vacancies, planning for retirements and to ensure that workforce numbers continue to reflect ongoing need.

As part of the implementation of the UHVP, a review of educational and continuous professional development (CPD) programmes for health visitors were undertaken. This led to two key changes. Firstly, relevant postgraduate education ‘Specialist Community Public Health Nursing’ (SCPHN) was adapted to support the refocused role. Secondly, to ensure additional training of existing health visitors to support the new educational components of the pathway, the Scottish Government funded a national Health Visiting CPD Programme delivered by Higher Educational Institutions to upskill health visitors and build confidence in delivering a more focussed role. This consisted of four days of CPD on Named Person, Leadership, Strength Based/Asset Based Approaches, Child Development and Quality Improvement Tools. Health Boards were asked to identify which staff required this CPD.

The UHVP ensures that health visitors have a structured home visit programme for all families, which includes an increased number of visits from what was previously delivered from at least 8 routine visits over the first 5 years to at least 11 visits. All families are entitled to receive at least eleven routine visits from health visitors, eight within the first year of life and three child health reviews between 13 months and 4-5 years. Additional support is also provided according to the level of need in line with a proportionate universalism approach, where the service is provided to all families but more of the service is provided to those with more need. The home visits begin from pre-birth until the child is five years old (or enters school). Figure 1.1 shows the expected UHVP visits.

At the home visits, health visitors undertake a holistic assessment of a child’s need for ongoing support and subsequently allocate the child to either ‘core’ or ‘additional’ using the Health Plan Indicator (HPI). An additional HPI (HPI-A) indicates that the child (and/or their carer) requires sustained (more than 3 months) additional input from professional services to help the child attain their health or development potential. Any services may be required such as additional health visitor support, parenting support, enhanced early learning and childcare, specialist medical input, etc. A child’s HPI can be changed at any time by the health visitor. For instance, an HPI allocated at the 6-8 week home visit can be amended at the 8 month home visit to reflect changes in the level of need.

To support and maximise the role and impact of health visitors within early years, the Scottish Government made a significant investment of £40 million (including over £3.4 million in health visitor training) over four years to enable the number of health visitors in Scotland to increase by 500 by the end of 2018⁷. This target was achieved and reported through National Workforce statistics ⁸. This substantial increase in investment in health visiting and the change in approach has necessitated an evaluation to assess the impact of the UHVP on outcomes for children and families and to identify further areas for improvement in the future.

Figure 1.1: UHVP visits⁹

A flowchart outlining the 12 stages of the Universal Health Visiting Pathway with contact starting pre-birth and concluding with a final visit and health assessment when a child is aged between 4-5 years. In total there are 11 home visits, with proposed national data collection points at 11-14 days, 6-8 weeks, 13-15 months, 27-30 months and 4-5 years old. There will be ongoing assessment using the GIRFEC Practice Model and HPI definition which is reviewed at 6 months. Further, there will be 3 home visits that involve a Developmental and Wellbeing review between 13-15 months 4-5 years old. The timeline of the contacts with a Health visitor via the UVHP is as follows;

Pre-birth:

• Pre-birth antenatal letter
• Antenatal contact: home visit at 32-44 weeks

Post Birth:

• 11-14 days: new baby home visit
• 3-5 weeks: 2 home visits
• 6-8 weeks: home visit
• 3 months: home visit
• 13-15 months: home visit
• 27-30 months: home visit
• 4-5 years prior to starting school: home visit

Pre-school:

• 4-5 ½ years: Transfer from outgoing named person (HV) to incoming named person (e.g. Education).

Additional changes introduced to the service included most health visiting teams across Health Boards discontinuing the delivery of child immunisations. Group clinics were also largely discontinued. The focus of health visiting teams also changed, moving from mixed skills teams (health visitors, community staff nurses, nursery nurses), to one where health visitors prioritised undertaking core child health reviews and acting as a main contact for families.

Implementation of the Universal Health Visiting Pathway

NHS Boards were asked by Scottish Government to introduce the UHVP to all pregnant women who booked for a first trimester screening scan from October 2015. This meant that these women should have had an antenatal visit by a health visitor at 32 to 34 weeks of pregnancy in March 2016. However, implementation of the pathway has varied between Health Boards, with Health Boards rolling it out at different times. Appendix 1 shows information from a questionnaire completed by all Health Boards. The results of the survey show the stage of the UHVP implementation within each Health Board as of September 2018. The timeline for ensuring all families receive the pathway was set at 1 Jan 2020¹⁰, which took into account the incremental increase of health visitors to undertake the role through a national recruitment exercise and local reviews of how the current mix of staff would fit into the new model of delivery.