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

2. Trusting relationships

In order for health visiting to achieve the outcomes for families envisioned in the design of UHVP, families need to be able to form trusting relationships with their health visitors. This ensures families are better able to ask for and accept the support on offer. A majority of the parents felt they developed a positive and trusting relationships with their health visitor. They also found their health visitors to be approachable, non-judgemental and professional and as a result, parents felt very comfortable approaching health visitors with concerns.

I think it’s more that she’s really supportive and I’m really comfortable with her and I know I can speak to her. I’m not scared and think oh God, she might judge me for that, or this has happened, or whatever if you know what I mean. I’m not scared to ask her a question, I know that she’ll just give me the right advice, and honest advice. She won’t, even though obviously she’s got the guidelines to stick by, but I don’t feel like I can’t approach her or anything, and that’s been really important because you know, sometimes in the world of parenting you get a bit like overwhelmed and scared, so it’s good to have someone you know you can go to (Parent, two children).

Very positive. She’s very...you know, it’s just a great relationship. She’s very friendly, reassuring, encouraging, you know, she’s just...I’d say she’s definitely fitted for her job. I’d say we get on very well. Definitely positive is probably the main...you know, it’s a positive relationship definitely (Parent, two children).

Health visitors also reported that the pathway has allowed them to strengthen and develop more trusting relationships with families.

Oh, definitely, yes, that’s probably the biggest advantage of [the pathway] actually, because you’re seeing that family from antenatal, you’re seeing the mum and then you’re going all the way through their journey with them, and [you are] able to build up relationships that way. You get to know your families a lot better. I would say that that is the biggest advantage of it (Health visitor).

The majority (92%) of health visitors reported having developed positive relationships with all or most of the families in their personal caseload (21% said ‘all’ and 71% ‘most’) – just 6% said they only had positive relationships with ‘some’ families and 1% ‘only a few’. Health visitors who had been delivering the UHVP for four years or more were most likely to report having developed positive relationships with all or most of their families (99%, compared with 92% overall).

Health visitors believed that having a more trusting relationship with families offered many benefits, including being able to build a better picture of the family from their own observations, which leads to more confidence in their professional judgement.

I think the benefit of the pathway, though was, if you do know your family, I sometimes have arranged to go in and do a visit at 13 months, because I know the family, I know the child. And I'm pretty sure the child is going to be able to complete that development. Whereas, there are other children where I'll say, I'm going to leave that, I'm going to delay that to 14 months, for example, because I don't want them to not succeed. Because they're still within the range. So that’s another benefit of having the pathway, and having that relationship with the family (Health visitor).

The main aspects of the pathway attributed to building trusting relationships were the frequency of visits or contacts (particularly within the first 6 months), the antenatal visit (already covered above) and the continuity of care and carer during this time.

Frequency of visits

The frequency of early visits was consistently reported as contributing to the development of positive relationships with families.

Particularly the visits, the early on ones where they are quite close together, definitely that’s the best way I think, the ones where it's later and I’m going into them and they are much older, I find them much harder to build the relationship with families because I’m only seeing them occasionally (Health visitor).

Health visitors mentioned that they used a range of communication methods to keep in contact with parents in between home visits, including phone calls, text messaging, emails and formal letters. Health visitors reported encouraging parents to contact them outwith pathway visits if any concerns arise. There was agreement among health visitors that families are more likely to contact them outwith pathway visits when a strong relationship is formed.

The pathway enables us to have a lot of contact with the families in the early six months, so therefore you have pretty much established if you are going to have a relationship, that’s where it's going to happen. And in fact, what we used to say for many years, if you don’t do that first new birth visit you won't actually get that really connected relationship because it's such a crucial time. So, the pathway being there has encouraged us and our managers behind and beyond, to employ more health visitors to allow us to deliver the pathway, so therefore it enables the creation of that relationship. 'Cause once that relationship is there, if the parent has a question, they are going to lift the phone and say, can I see you, I’ve got a wee worry, it's probably nothing, can I talk to you? (Health visitor).

The above quote indicates the positive developments that can happen when a good health visitor-parent relationship is developed.

One of the ways to assess the quality of the relationships between parents and health visitors is to explore the extent to which arranged visits successfully took place. This was scrutinised within the case note data. Table 2.1 shows the number and proportion of cases in which at least one arranged visit did not take place (we describe this as “missed visit” because the health visitor made an attempt or actually visited the house of the family, but parents were not available). There were considerable variations between Health Boards, with 10 of the 15 cases in HB5 missing at least one arranged visit. Only two cases, out of a total of 15 cases missed at least one arrange visit in HB4. Overall, in the majority of cases (58%) there were no missed visits. However, in 42% of cases there was at least one arranged visit that did not take place.

Within families that were receiving the core pathway the number of visits that did not take place was (42%), while this was 44% of visits for families assigned HPI-Additional.

Table 2.1 Number of cases where at least one arranged home visit did not take place

Health Board	Total cases (N=73)	Total number of cases where at least one arranged visit did not take place (N=31)	Proportion of cases where a visit did not take place for ‘HPI - core’ families (%)	Proportion of cases where a visit did not take place for ‘HPI – Additional’ families (%)
HB1	15	7	4/10 (40%)	3/5 (60%)
HB2	13	5	4/8 (50%)	1/5 (20%)
HB3	15	7	4/10 (40%)	3/5 (60%)
HB4	15	2	1/11 (9%)	1/4 (25%)
HB5	15	10	7/9 (78%)	3/6 (50%)

Table 2.2 further examines the timepoint in the pathway when missed visits occurred. It appears that there were no clear patterns across the pathway for families assigned either HPI-Core or HPI-Additional. However, the data indicates most of the planned visits that did not take place occurred when children were less than eight months old.

Table 2.2 Age of child and HPI allocation in relation to missed visits

Health Board	Antenatal and up to 8 weeks	8 weeks to 4 months	4 months to 8 months-	8 months to 13-15 months	13 – 15 to 27 – 30 months	Over 32 months
HB1	1 x Core	1 x Core 3 x Additional	0	1 x Additional	2 x Core	1 x Core
HB2	1 x Core	4 x Additional	0	2 x Additional	3 x Core 1 x Additional	0
HB3	1 x Core 1 x Additional	1 x Additional (4 times)	0	0	0	0
HB4	1 x Core	0	0	1 x Additional	No case records reviewed
HB5	3 x Core 1 x Additional	2 x Core	1 x Core 3 x Additional	0	1 x Additional	1 x Core

The parents’ survey also asked about how often parents saw their health visitor in the 12 months prior to the COVID-19 pandemic, which led to the onset of the national lockdown in March 2020. Any interpretation of these survey responses should take into account the actual number of contact health visitors should have with families at different age points according to the UHVP Guidance (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)

Given there are a greater number of visits in the early stages of the pathway, there was substantial variation in the number of contacts (by phone or in person) parents had with their health visitor in the 12 months prior to the March 2020 lockdown depending on the age of their child. As Table 2.3 shows, almost all parents of children aged one or under had seen or spoken to their health visitor (either by phone or in person) at least once in the 12 months prior to lockdown in March 2020, compared with around half of parents of 4 or 5 year olds (these contacts could have been as part of the main pathway visits or out with those visits). The average number of contacts was between 5 and 6 for parents of children aged one or under, and 4 for parents of 2 year olds, before falling to just under 2 for parents of 3 year olds and just over 1 visit for parents of 4 or 5 year olds. When comparing this to the expected minimum number of visits in the pathway for each of these stages, the minimum number of visits is 8 visits for children up to one year old, one visit at 13-15 months, another visit at 27-30 months and the remaining visit occurs when children are between 4 and 5 years. So, there was not much variation in terms of the actual and expected contacts. For parents of children aged one or under, an average between 5 and 6 seems less than expected, however, it is likely that these children are not up to one year and are likely to receive additional visits or contacts with the health visitor before their first birthday.

Table 2.3 Contact with health visitor(s) in the 12 months prior to lock down in March 2020

	All	Child aged 1 or under	Child aged 2 years	Child aged 3 years	Child aged 4 or 5 years
No contact at all	27%	2%	6%	28%	47%
1 contact	29%	8%	32%	43%	27%
2 contacts	12%	11%	20%	11%	8%
3 contacts	9%	11%	11%	9%	7%
4 contacts	5%	10%	10%	2%	2%
5-9 contacts	12%	41%	11%	5%	3%
10+ contacts	5%	9%	6%	2%	2%
Base	537 (All parents with babies born prior to lockdown)	96	100	133	207

The average number of contacts for the 12-month period reported on was higher among parents aged under 30 years, who reported almost 5 visits on average, compared with just under 2 among parents aged 35 years and above. This is likely to reflect the fact that, in general, older parents in the sample had older children (who are scheduled to receive fewer regular visits under the pathway).

Continuity of care and carer

Improved continuity of care and carer is a key aim of the UHVP. An important feature of the UHVP is that the same health visitor or fewer different health visitors support individual families over time, increasing opportunities for building trusting relationships with families.

Across all case study areas, it was clear from the qualitative interviews that it was often the same health visitor that delivered the pathway visits to families in their caseload. In particular, the focus groups made clear that health visitors ensured that the same health visitor delivered all the visits to families requiring additional support.

I would agree with that, we would try and keep [HPI] additional families, wherever possible, the same health visitor (Health visitor).

The survey data of health visitors provides further information about continuity of care and carer. Most health visitors (59%) reported that they personally make all of the pathway visits to the families in their caseloads, a further 37% make them to most families and 3% to some of them. Those in the West Region were more likely to report making all of the visits (68%) than those in the North (56%) and East Regions (38%).

Examination of health visitors’ case notes revealed that most parents had more than one health visitor delivering the pathway visits, as illustrated in Table 2.4. While a third were shown to have one health visitor, almost half had two or three health visitors contributing to the case notes. Where there were 5 or 6 health visitors involved with each family, closer scrutiny established that this was more likely for families that were HPI-Core rather than HPI-Additional.

Table 2.4 Total number of health visitors contributing to each case note

Health Board	1 HV	2 HVs	3 HVs	4 HVs	5 HVs	6 HVs	Total cases where evidence of numbers of health visitors gathered
HB1	4	5	2	0	0	1 (HPI Additional)	12/15
HB2	3	4	3	3	0	0	13/13
HB3	3	3	3	4	1 (HPI Core)	0	14/15
HB4	7	4	2	0	1 (HPI Core)	0	14/15
HB5	4	4	2	1	0	1 (HPI Core)	12/15

The survey of parents explored the extent to which parents were experiencing continuity of care and carer for their child in the early roll-out or pre-UHVP phase, in terms of how frequently they saw the same health visitor.

Overall, two thirds of parents (67%) said that they had one main health visitor who they have seen for most of the time, while one third (31%) said they did not. This contrasts with the health visiting survey findings above. There were more parents of older children in the survey sample and it is less likely they see same health visitor over longer periods of time and during the implementation of the pathway, before it became fully embedded.

From the survey results, among the 31% of parents who had more than one main health visitor, 23% said they had seen two different health visitors, 42% had seen three, and 24% had seen four or more (11% were not sure how many different health visitors they had seen for their child). The average number of different health visitors that parents reported having contact with (among the minority for whom this was more than one) was three.

Furthermore, those with younger children were more likely to report that they had one main health visitor – 100% of the small number of parents (n = 33) answering for a child aged under one said they had one main health visitor, falling to 74% of parents of one-year olds, 73% of parents two year-olds, 65% of parents of three year-olds, and 59% of parents of children aged 4 or 5 years. This may reflect the way the UHVP has been rolled out across Scotland. Nevertheless, to maximise the impact of the pathway it is important to ensure that parents see the same health visitor throughout the entire pathway. There were no clear significant differences in whether or not parents reported having one main health visitor by parental age, working status, income, or deprivation.

The most common reasons reported by health visitors and parents for families receiving visits from multiple health visitors during the pathway were annual leave, sickness or emergency situations (e.g. when the safety of the family is at risk). These issues necessitated the need for alternative arrangements, where in most cases another health visitor covered the caseload of the substantive health visitor.

Among the pathway visits, health visitors mentioned that the visits most often prioritised when taking a planned absence from work were the birth visits and visits for families assigned HPI-Additional. Health visitors elaborated that the standardised nature of the pathway helped to facilitate any temporary caseload cover.

But if somebody is off sick or on holiday, you know exactly what point they're at. Because you know, right, it's that five week visit, therefore this is needing discussed. I know we all maybe tweak it slightly differently, but you pretty much know the information that, the health promotion information that needs to be delivered at those points (Health visitor, Focus Group).

It appeared that in some Health Board areas, health visitors still relied on additional skill-mix staff (community staff nurses and nursery nurses) to undertake certain pathway visits, especially for core families as one health visitor explained.

We always try for the first year that it will be the same health visitor that sees the family. If the family were an additional family, then we would do the 27-month review and the four-year check. If they were a core family, the 27-month review and the four year would be done by the nursery nurse (Health visitor).

In one of the focus groups, health visitors reported that there was fragmentation in the continuity of care for families transferring into the health visiting service after receiving support from the Family Nurse Partnership (FNP)^[1]. Health visitors discussed the way that building relationships with families who had previously been in receipt of the FNP programme was challenging due to the change of practitioner and the timeline of the pathway, which offers two visits to ‘core’ families at 27 and 48 months after the initial handover visit at 24 months. It was noted that forming relationships at this stage was challenging for both health visitors and families. Health visitors also felt that the lack of continuity of carer and decreased level of support in comparison to what was offered under the FNP programme impacted negatively on families.

We see them at two, for a handover visit, with very intensive support, up until two. We see them for the handover visit, we see them at 27 months, and if they're core children, we don't see them again until they’re four. There’s lots of scope to miss things, I feel, there's huge gaps in that. And the parents, the families that I've worked with, have reported back that they feel abandoned, some of them will say. That they’ve had the family nurse intensively up ‘till age two, and then they’ve got nobody because our timeline says, 27 months, and 48 months. So, I feel that creates more problems. You don’t have a relationship with the family, it’s very difficult for them and difficult for us as well (Health visitor).

Understanding the effects of trusting relationships

Contacting health visitors

Trusting relationships between parents and health visitors can create a positive atmosphere for parents to contact and talk to health visitors. The survey data shows that seven in ten parents (71%) agreed they could talk to their health visitor about anything (43% strongly agreed and 28% tended to agree). Seventeen percent disagreed with this statement (9% tended to disagree and 9% strongly disagreed) and 11% neither agreed nor disagreed and 2% did not know. Parents of children aged one or under were more likely than those within children in the older age groups to strongly agree that they could talk to their health visitor about anything (55%, compared with 43% of those answering about a 2 year olds, 41% answering about a 3 year olds and 38% of those answering about a 4 or 5 year olds).

In the qualitative interviews, parents said they felt able to contact health visitors by phone regarding issues affecting them or their baby because of the trusting relationships they have developed with them.

Oh, sure. Even like discussing [my baby’s] milk and formula and things, I was in the shop one day, I was trying to look for like a reflux milk, so I couldn't find it at all. I phoned [my health visitor] in a panic, I was like I can't find this milk, oh my God, and she said don't worry, you can get this, this and she went through all the different ones with me. I literally just phoned her out of the blue because I was like what do I do here (Parent, first time).

Yeah, absolutely, so she is always on the end of the phone and I can just leave a voicemail and generally the same day she would get back in touch (Parent, three children).

However, parents’ accounts of the health visitors’ ability to respond promptly was not universal. A number of parents mentioned that they did not receive a prompt response from their health visitor, and one parent mentioned that part-time working pattern of the health visitor means it takes a little longer to receive a response.

I mean the only very slight negative is sometimes with, are, you have to, sort of, leave a message and wait for somebody to ring you back and it’s not always the same day, which is fine, like, I do understand they’re out and about. But I mean, that’s the only thing sometimes it’d be good to have a slightly quicker response if you need them. But apart from that, I really, you know, they’re very approachable, helpful, friendly and I’ve been really pleased with the whole process (Parent, four children).

Yes, the difficulty in our region is our health visitor only works part time. If you had to contact them outwith those hours, sometimes it could be a wee bit longer until someone got back to you (Parent, two children).

The inclination of parents to contact health visitors seemed stronger when parents felt confident in the health visitor’s level of knowledge and ability to provide them with the necessary information or support.

Yes, it’s good. She’s very open and friendly, very knowledgeable. She’s often there when I go to the health clinic to do the weigh-ins that you can get when you need them, just to make sure the baby’s okay. She’s often there. Yes, I feel like I can ask her anything; really, really knowledgeable, good ideas so, yes, I think it’s very good (Parent, three children).

Yeah, it’s good. [My health visitor] is easy to get on with. [My health visitors] is a very cheery, happy person and quite informative. [My health visitor], as I say, we’ve got a contact number for them. If we need [my health visitor], we can contact them directly. And there is an office number if we can’t get hold of them (Parent, first time).

On the other hand, a couple of parents also mentioned that it was likely they would not contact their health visitor for support if required. However, this didn’t appear to be a consequence of a poor relationship with the health visitor. Some of these parents empathised with health visitors’ workload and assumed that others may require support more than themselves. Some parents also mentioned that in the situation of any urgent concerns, they would rather make contact with their GP. One parent explained:

I’m not sure if I would contact them, actually, maybe because of some of what I mentioned about feeling checked up on. We don’t have any, like, real issues, I guess, but I’m not sure if I would contact them for support. I know other people have, but they seem quite busy. It’s quite last-minute when we get our appointments through, and so unless it was something quite major, I don’t think I would go and speak to them. And if it was something more urgent, I might end up going to see my GP instead, maybe, because I know them a bit better. I guess I have an awareness of what you might go and see a pharmacist or a GP for, but not necessarily a health visitor (Parent, two children).

Listening to concerns

The parent survey also explored whether parents felt their concerns were attended to once they contacted their health visitor. Eight in ten parents (81%) agreed that their health visitor listens to their concerns either ‘very’ (51%) or ‘fairly’ (30%) well. Just 10% said that they did not listen ‘very’ (6%) or ‘at all’ (4%) well while 8% did not know. As before, parents with younger children were more likely than those answering about older children to respond positively – 63% of parents of children aged one or younger, or aged 2 years felt their health visitor listened ‘very well’, falling to 52% of parents answering for a 3 year-old and 38% for a 4 or 5 year-old. There were no other significant differences between parents of different ages, household incomes, or those living in different Health Board regions.