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

4. Partnership working with other agencies

Health visitors’ views on how the pathway promotes multi-agency working was explored. In the survey, half of the health visitors felt that the UHVP has had a positive impact on providing opportunities to work with other agencies (13% a major positive impact and 37% a small positive impact), 43% felt it had made no difference one way or the other while 5% felt the impact had been negative (4% major and 1% small). Those who had been practicing for 10 years or more were much less likely than others to think there had been a positive impact (35%, compared with 50% overall).

In the qualitative research there were mixed findings when health visitors were asked to comment on whether they felt the pathway promotes multi-agency working. Those who responded that it created opportunities for multi-agency working explained that the frequent visits embedded within the pathway promoted timely referrals to relevant agencies and the ensured interactions with these agencies. These were also facilitated by the visual representations of the pathway that helped to create awareness about the role of health visitors and the nature of the pathway.

I think the pathway is good as well for other agencies seeing what health visitors do, and what they deliver, as well. Which is, you know, beneficial. Because I think a lot of people out there were like, what do health visitors actually do, you know, with babies, you know. So in that sense, you can see, you know, what we’re delivering, and other agencies can see that as well. So it's quite good from that point of view (Health visitor, Focus Group).

I suppose the other thing I like about the pathway is – and I’m not sure if this is the right place to mention this, but I like the visual aspect of it, so not everyone does but I put this in the front of the parent health record so that parents can see what’s going on and I write my visits in here at the front, they know, they can plan what’s happening next, look at the front, but I can also use this with other professionals to show them what we do, and I think that was one of the issues before, it was quite hard to explain what health visitors do. So I think it gives a visual representation of how we support parents and children is useful, yeah (Health visitor).

The broad areas that the pathway covers were also regarded as opportunities to engage with different professionals.

Yeah. I think it does because I think it includes lots of different things. You know, there’s lots of different…child smiles, play at home, speech therapy, you know, community paediatrician, social work home start, charity organisation. So, I think that is included within the pathway, in terms of trying to sign post people to different resources and community organisations that would be useful. So, I think, in terms of that, yeah. I think there’s a lot of information within that that was useful. Particularly, I think, if you were new into the post. Or newly qualified (Health visitor).

They also believed that the pathway had introduced more structure into how they engaged with other professionals, especially when dealing with requests for assistance^[5].

Yeah, definitely, it has changed [multi-agency working]. I think there was a lot more ad hoc type of requests for, you know, assistance. So, you know, whereas now we have the different stages, as I say the different developmental stages. They’ve always been there but I think it’s probably a little more key sort of, you know, because it’s...those particular developmental stages are being done within that timeframe, you know, whereas before maybe it was a little bit ad hoc. So for example we didn’t have a 13 to 15 month assessment and that’s obviously incorporated into the pathway. And I think, you know, we’re not missing some of these babies who might present with various issues and problems, and we might then not have seen them till 27 to 30 months, so we’re able to kind of, you know, assess things and detect things at various different stages. And I think our colleagues, you know, other health professionals, they’re now aware of the universal pathway, they’re aware of all the different developmental kind of types of visits (Health visitor).

Similar to the findings of the survey, other health visitors expressed the view that the pathway had not influenced any change in multi-agency working and that this had therefore remained the same. Some explained that other factors, have contributed more positively to multi-agency working rather than the pathway such as the use of the Getting It Right For Every Child (GIRFEC) national model and approach.

I don't know if it promotes it as such, I think that we do that anyway, so I would have done that regardless, even before the pathway, so again for me, personally, probably not. I don't think the pathway has been the key to that. I think there has been other things like GIRFEC that probably has done that rather than the pathway (Health visitor).

In the case note review, health visitor attendance at multi-agency meetings related to the baby/child was evident throughout. In most cases the children involved were predominantly allocated to HPI-Additional. The purpose of the multi-agency and multi-disciplinary meetings predominantly relate to child protection systems and processes.

Engaging families with relevant services

Supporting sustained engagement with relevant support groups or services is another ambition for UHVP. Many health visitors reported that the intensity of the pathway helped them to make timely referrals to relevant services. The services or professionals that they felt they most frequently engage families with were speech and language therapists and early learning and childcare professionals.

It was mentioned that there had been changes in other services too and it was difficult to ascertain whether the delivery of the pathway had changed the way health visitors engaged parents with other services. For instance, it was noted that one Health Board used to have a long waiting list for Speech and Language Therapy, but this had been addressed independently of the pathway.

From what it seems we had our transforming health visiting pathway put in place and it seems that other agencies have also done a bit of transformation for their services. Well, particularly speech and language where there used to be a year’s waiting list but now there’s not a waiting list, which is a big difference in the area (Health visitor).

Health visitors in one Health Board reported that while they were able to identify concerns, it was problematic when relevant services required to provide support were not accessible to families at times. For example, speech language therapists had long waiting list, and this hindered access to such services. Although health visitors said that the waiting times would not influence their referral decisions, they further explained that at times they engage nursery or assistant nurse practitioners to provide interim support to such families whilst waiting for the services from the appropriate agency.

I would say yes it has improved that. Yes, it has improved that. But the knock-on effect is because we’re picking up things a lot earlier, which is good for the children to make sure that they reach their full developmental potential by the time they get to school, but the services are not quite there for the number of children that are being picked up early (Health visitor).

Speech and language is probably about an eight month waiting list, so I suppose if there is not really that much out there, if so I probably would refer anyway but in the kind of interim period I would probably link in with the assistant nurse practitioner or the early years speech and language therapist to make sure that a child was still having some kind of intervention whilst waiting the eight months. So, I probably would still refer but I would still be looking for other services to help in the meantime (Health visitor).

In one Health Board, health visitors highlighted that measures had been put in place to overcome long waiting list for speech and language therapy. For instance, they mentioned that the early communication drop-in clinics for families had helped ease the pressure on speech and language therapists and provided them with an important avenue to refer families requiring such services.

I don’t know if, say, for example, the early communication drop-in clinics that the Speech & Language therapy provide, I don’t know whether that’s necessarily linked with the pathway as such, but that’s been a fantastic resource to be able to refer…tell parents about so that they don’t need to wait a couple of months to see a speech therapist, they can go straight away to any clinic in [this area] and be seen – I think that type of service has been fantastic (Health visitor).

Health visitors felt that the pathway had also facilitated the discussion of certain issues, such as gender-based violence, which was discussed less routinely in the previous offering. Health visitors felt this enabled more timely referrals for these types of concerns.

I would think [the pathway] maybe makes referrals a little bit quicker. Things like, I think, gender-based violence…gender-based violence it’s quite routine within the pathway now, and people are talking about it more, and it’s not a difficult question to ask. So, I think for getting support in those areas it’s… I think the pathway’s enabled us to make referrals quicker, sort of, to support services (Health visitor).

A few health visitors reported that the pathway enabled early identification of strengths and concerns and had increased the overall number of referrals, which had inundated other services.

…I think more has developed since the introduction of the pathways because a lot of services must have been inundated with referrals when we started doing these regular contacts. So, they’re actually putting together packages so that we can access resources before we refer. So, it’s about having that tier one availability and support, so I think that’s probably the biggest impact (Health visitor).

The survey found that health visitors who had been practicing for 10 years or more were much less likely than others to think there had been a positive impact of the pathway (35%, compared with 50% overall) in terms of engaging families with other services. Similarly, in the qualitative research, some of the more experienced health visitors disagreed that the pathway enabled them to link families more to relevant services compared with what they were previously delivering prior to the pathway. However, they acknowledged that the pathway added some additional value around the identification of concerns and referral processes.

It hasn’t made that any better because I always did that anyway because it was a core part of my job. So the only thing I would say is that maybe the relationship building thing again and maybe some of the specific enquiries round for instance domestic abuse may make it more likely to, yeah, to highlight something that needs referral (Health visitor).

The survey also asked parents whether their health visitor had ever requested help from, or suggested that they contact, any other services. Fifty-nine per cent said they had been referred to a service while 40% had not. The 59% who had been referred to a service were then asked whether they had contacted a service as a result of their health visitor’s suggestion. Ninety-one percent of these parents had, while 9% had not.

The specific services referred to and contacted are shown in Table 4.1 below. As shown, the services parents were most commonly referred to were: local doctors/GPs (35%), other services that support parents of young children (e.g. parent and baby/child groups, Children’s Centres) (27%), other health services (e.g. Audiology, Optician, Speech and Language Therapy, Dietician, Child and Adolescent Mental Health Services) (22%), Paediatrician (13%) and Practice Nurse (11%).

Table 4.1 Referrals to wider services

Service	% of parents who were referred to service by HV
Local doctor/GP	35%
Other services that support parents of young children (e.g. parent and baby/child groups, Children’s Centres)	27%
Another Health Service (e.g. Audiology, Optician, Speech and Language Therapy, Dietician, Child and Adolescent Mental Health Services)	22%
Paediatrician	13%
Practice Nurse	11%
Services that offer help accessing childcare	5%
Services that help with food money or housing issues	3%
Social worker	3%
Any service	59%
No service	40%
Base: all parents (550) and all parents referred to a service (322)

Older parents were less likely than younger parents to have been referred to any service (54% of parents aged 35 year and above versus 67% of 16–29 year-olds and 65% of 30-34 year olds). Parents living in the most deprived areas (SIMD 1) were also more likely than those in the least deprived areas (SIMD 5) to have been referred to a GP specifically (41% versus 27%).

In the qualitative interviews with parents, it appeared that first time mothers and parents new to an area found engagement and signposting to groups and services more beneficial. In the quotes below, one parent explained how the health visitor helped her to engage with baby classes and baby sensory and massage classes. This she felt was important as she was feeling a little isolated. Another parent mentioned that the health visitor was instrumental in terms of engaging her with the groups in the new area she moved to.

Yeah, definitely, because obviously being a new mum I didn't really know anything about baby classes or anything like that, so [my health visitor] was always quite keen to…I guess because I was by myself as well, so she was quite keen to get me like moving and out and seeing people instead of being stuck in all the time. She told me about baby sensory and massage classes and things like that, so she got me involved in them and I went to them, so I did (Parent, first time).

So, definitely able to signpost me to…there’s a group called [name withheld], which is held up in the library. It’s got a playgroup and different activities going on at different points for different ages of babies and toddlers. So, health visitors were definitely able to signpost us to there. And they've also spoken about a playgroup that might be suitable for [my child] when she’s turned two. So definitely, being able to signpost to that. I think when I first moved through, [my child] was only four weeks old. And it was really useful that they were able to signpost me to the one up at the library locally (Parent, two children).

A further exploration of how health visitors engaged families with other agencies was examined within the case note review. Evidence of effective communication with services can be demonstrated where other agencies identify their concern about children to health visitors. The case note review identified that concerns about children were communicated to health visitors from other agencies such as social workers, nursery teachers, police, and other healthcare professionals. An example from HB1, illustrated in Table 4.2 below, shows the types of concerns raised by other agencies that were relayed to health visitors.

Table 4.2. Concerns which were communicated to health visitors in HB1 from other agencies

Child’s age or gestation of mother	Concerns identified by other agencies and shared with health visitors
17 weeks of pregnancy	HV notified by SW that father known to Criminal Justice
1 week	Prebirth concerns communicated from SW to HV
27 months	SW notified HV that mother homeless due to relationship breakdown
3.5 years	Nursery teacher informs HV that they are concerned because child fails to be brought to nursery

There was also evidence in the case notes that health visitors were notified of children’s attendance or non-attendance at other service or agency appointments.

In each of the five Health Board areas the case notes review evidence related predominantly to information from other health disciplines. This does not fully reflect the range of agencies or disciplines referral are made to by health visitors. It is also possible that information about child attendance to other appointments may be held in another agency’s repository.

Health visitors and the appropriate use of health services for children

In the case note review, we explored how health visitors support the appropriate use of services for children. For instance, some records had dental registration identified (see Table 4.3), however the timeframe of when this was recorded varied. In reviewing the records, it is evident that ChildSmile discussions, and referrals, take place in the first few weeks. However, dental registration is not recorded until it has been confirmed by the health visitor. Health visitors are informed of dental registration at 27 – 30 month review, however the majority of children in the case note review sample had not reached this age at the time of the data gathering process. This means they had not reached a stage where this information was recorded by their health visitors.

Table 4.3 Registration with a Dentist

Health Board	Evidence of noting of dental registration status in record	No evidence of dental registration status in record	Total records reviewed
HB1	8 (most common time for recording is at 27-30 month review)	5	15
HB2	10 (most common time for recording is at 13-15 month review)	3	13
HB3	9 (an equal range of times when recorded; 6-8/52; 8/12; 13-15/12; 27-30/12)	6	15
HB4	6 (frequently at 13-15/12 – but a number of cases not at this age yet)	9	15
HB5	9 (a range of times but most frequently recorded x 5 – at 8/12 review)	6	15

General Medical Practitioner (GP) registration is predominantly discussed, addressed and recorded early within the Pathway visits, as could be seen in Table 4.4.

Table 4.4 Registration with a General Medical Practitioner ( GP)

Health Board	Evidence of noting of GP registration status in record	No evidence of GP registration status in record	Total records reviewed
HB1	8 (usually noted at 6-8 weeks)	7	15
HB2	10 (noted at First NB Visit and 6-8/52 Review)	3	13
HB3	13 (acknowledged but no date on data gathering tool)	2	15
HB4	14 (predominantly noted at First NB Visit)	1	15
HB5	15 (10 x logged at First NB Visit)	0	15

Data on parents’ use of services or agencies which provide emergency treatment and care for their child was collated. The number of visits appeared to increase after six months of age. The reasons for attending A&E/Out of hours are provided in Appendix 12. Whilst informative, without knowing the clinical circumstances it is not possible, or appropriate, to make a judgement about whether the health visitors have been able to support the appropriate use of emergency or urgent care in these cases.

Knowledge and awareness of local groups and services

In order to understand how health visitors engage with other services. It is important to explore their knowledge and awareness of groups and services within their local area. It was anticipated that the pathway would enhance health visitors’ knowledge and awareness of community assets and referral pathways. Often, knowledge and awareness of local services were area dependent, with some areas, having a directory or local list of all services available in that particular area. According to health visitors, community profiling in terms of identifying relevant local services and signposting families to these services has always been part of their role, therefore many felt the pathway has not enhanced their knowledge and awareness of these services.

I don’t think the pathway has done that [enhanced knowledge and awareness of community assets and referral pathways]. I think as a health visitor with your community profile that you do, like I’ve been in [this place] for a year and a half, so when I first came to [this place] a big part of what I did was going to find out what there is. I don’t think the pathway does that for us, I think you do that as a health visitor yourself, I don’t think it really does that at all…as a health visitor that should be your bread and butter. That’s something I teach when I’m a community practice teacher, you know that’s the kind of thing – go out and find out what there is (Health visitor).

Very few health visitors from the interviews and focus groups, including newly qualified ones or those who have relocated from a different Health Board area found the pathway to be helpful in terms of facilitating their knowledge and awareness of community assets and referral pathways. Most explained that the pathway had not directly enhanced their knowledge of community assets, however its inherent timeline facilitates signposting of families to services relevant to age and stage of the child.

But I mean, I think the pathway does signpost different places that you’re able to refer into. And the kind of time that you’re doing it, you know what’s right for the child and 13-month review safety features because of the age and things like that, so you’re able to signpost them to groups and initiatives and things (Health visitor).

Health visitors who are new to a Health Board area may not be fully aware of the groups and services in that particular area. This means they may be unable to engage families with relevant local groups and services. One parent explained that she had to do her own research to identify relevant groups and services in her area and informed her health visitor about it.

…I had happily found out myself and told her that, and she just asked how they were and stuff, so, yes, probably just did it myself. But she did, you know, ask about it, so, yes, that’s fine (Parent, three children).

It was clear that some parents had local knowledge of groups and services in their local area. They also found out more about groups and services through networks of similar groups and services.

Yes she has, she did tell me about groups that are happening yeah, I mean, I did a lot of…I found out about a lot for myself, it’s one of those things if you go to a group, people tell you about other groups that exist as well (Parent, first time).