A realist evaluation of the enhanced health visiting service in NHS Ayrshire and Arran

Executive summary

In the middle of 2013, NHS Ayrshire and Arran transformed their health visiting service with more focus on pre-birth to 5 years. Also introduced was a universal assessment timeline that ensures that children and families receive at least ten home visits.

These service changes are set within the wider context of the recommendations of NHS Scotland Chief Executive Letter (CEL) 13 (2013), which aims to refocus health visiting and school nursing roles, to improve care delivery within the community and tackle health inequalities.

The primary aim of this evaluation was to understand how the enhanced health visiting service (including the universal assessment timeline) in NHS Ayrshire and Arran works for both parents and health visitors, with a view to inform the implementation and evaluation of CEL 13 (2013) and a structured, increased home visiting service in Scotland.

A realist evaluation design was considered to be the best approach to answer the research aim and objectives. Realist evaluation seeks to understand how a programme works rather than providing a verdict of whether the programme works or not. It has three distinct phases: phase 1 defines the programme theory; phase 2 tests the programme theory; and phase 3 provides an explanation and refinement of the programme theory. In phase 1, eight managerial staff who were involved in developing and implementing the programme provided data, which were used to construct a logic model (programme theory). In phase 2, the theories were tested using qualitative data from 25 health visitors who delivered the service and 22 parents who received the service. In phase 3, all the data were brought together and explanation of how the programme works was provided.

The evaluation identified the following key findings:

What worked well?

Parents' increasingly viewed health visitors as their first point of contact on wellbeing and developmental-related issues. This was primarily due to more trusting relationships they have developed with health visitors through the enhanced programme. They also felt comfortable contacting health visitors by phone. Although this was possible in the previous service, however, health visitors reported that the frequency of contacts had increased.

Both parents and health visitors reported that the service changes have improved early identification of concerns (about both parents and children) leading to early engagement with wider services, including nursery services, in ways that were not previously possible.

Health visitors felt that the changes have made their role much clearer and well defined. They perceived that this has enhanced their professional partnership working.

What may need further consideration?

Both parents and health visitors found the gaps between some assessment visits in the timeline too wide apart.

Some health visitors, were concerned about referral pathways. They felt they were cumbersome and presented significant challenges to the enhanced service.

Health visitors universally acknowledged that increased home visiting has been challenging and reported that they struggled to fulfil the entire timeline. This prompted some areas to involve staff nurses and skill mix to fulfil the timeline.

Some parents and health visitors missed the drop-in clinics, which were largely stopped when the enhanced service was introduced. For parents, the key reason why they still wanted the clinics was the opportunity to build social support networks.

The enhanced health visiting service in NHS Ayrshire and Arran is currently being delivered with limited resources, yet this evaluation demonstrates a number of positive findings in terms of the value it has added to health visiting practice and indicates promising improvements in outcomes for children and families. There are some findings which the nation-wide roll-out may wish to consider to ensure favourable outcomes, but overall this evaluation should be reassuring for the impending implementation of the programme across Scotland, which promises to offer more resources than are currently available in NHS Ayrshire and Arran.