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

4 What did health visitors say?

4.1 This chapter presents the findings of how the programme works in practice from health visitors' perspective (phase 2), by examining the assumptions outlined in the logic model. Using the logic model, eight themes were identified.

Prevention and early identification

4.2 Almost all the health visitors acknowledged that they have found the structured, increased home visiting hugely beneficial. They particularly appreciated the focus it offers in terms of prevention and early identification of concerns.

I think it's made me far more aware of my families. I would have missed lots of things, and I would end up having lots of families in crisis. And it would be crisis intervention, rather than prevention, and that's not how to do it. A child should never get to the stage where their family is so chaotic that they have to be removed. So, for me, I wouldn't have been in the houses as often as I am now (H23).

4.3 The majority of health visitors were keen to add that with the previous service, concerns were often identified at advanced stages. They stressed that this was the case particularly for some core families as described by one health visitor below.

There are real benefits - I don't know whether it helps to say, previously we had examples of children - and not necessarily children who would come through on that vulnerable pathway, so not families that previously might have been monitored more closely by health visiting before the introduction of the timeline. Those kind of more affluent, professional families where you look at the family and think, oh mum knows what she's doing, everything's fine, but it happens with the second sibling, but actually when they've then come into their pre-school or ante-preschool setting, it's been a child that people have gone to see, Oh my Goodness, nobody has picked up that there is a significant issue with this child, because actually mum and dad haven't taken them anywhere, haven't engaged because there wasn't that routine visits (H15).

4.4 Some health visitors added that the changes have placed them at a better position to build a good understanding of children and families' concerns from the very beginning, and take action if necessary, or possibly observe over time whether those concerns would be confirmed or allayed.

And it gives you the chance to build up a better picture I suppose, because if you're seeing them right at the beginning then you can see if there's any deterioration, or any differences that would maybe raise concerns. Or it would reassure you that the family are doing okay, because there have not been any changes over the past maybe four or five months. So it just lets you see how...instead of them coming to a clinic, because when they're coming to a clinic that can be completely different. When they're in their home environment you get to see exactly what they're like (H20).

Home visiting versus drop-in clinics

4.5 Health visitors felt that the benefits of the home visiting were far greater than the previous drop-in clinics. A number of them acknowledged that the home visiting put much more focus on families than the drop-in clinics.

Home visiting has given us much more control over, sort of, prioritising what we're doing for families, you know, whereas before when we, sort of, you were, kind of, it's clinic time and you had to work around that, you know, and it was more around fitting people in around that rather than, sort of, being led by the needs of families you were working with (H16).

4.6 They believed that the home visiting provides clear opportunities to identify more concerns. They explained that it was impossible to observe and identify such concerns in the previous service.

Well, I think I had a family that I visited quite frequently at home, and the pattern became that this child was probably left alone quite a lot in the mornings. The parents weren't very good at getting out of their beds. And I think that became more apparent because I was visiting at home, because when you go at home, you hear the child crying, and the parents aren't responding. They took a long time to answer the door, and when you go in, the home environment is not great, the child is maybe running about with a really wet nappy on. Whereas, I think if it was a clinic setting, they might not come on time, however, the child will probably be well presented, because they know they're coming (H18).

4.7 Some health visitors also felt that the home visits were hugely beneficial in terms of providing targeted support to children and their families.

One family I can think of off the top of my head, I've known that there's been issues going on, but the fact that I've been going in more proactively, I've been able to get different services in and even getting those services in within two weeks. I've seen huge differences to that child. So whereas maybe previously, all that might not have been as timeously (H22).

4.8 Interestingly, even those who initially thought that the structured, increased home visiting was unnecessary and would not be beneficial to parents as it was too intrusive, acknowledged how valuable they have found it.

I used to think that we should still have kept our clinic going, but actually, see now, I'm happier doing the home visits. I don't mind doing the home visits, I think it gives you a better picture, because as I say, they could come to a clinic and be all completely nicely dressed, but you don't know what's going on in the background. So I do like the fact that all our visits are done at home (H12).

4.9 However, some very few health visitors still believe that the drop-in clinics were more useful than the home visiting. They even suggested that some parent preferred them more than the home visits.

I've got mums who would probably prefer to go into the clinic but that's not an option for them now so probably you're taking choice away. I personally don't think there's a benefit (H3).

Health visitor-parent relationship

4.10 Professional and client relationship is integral to effective health visiting practice (McKee and Queen, 2004). Ongoing positive relationship between clients and health visitors can maximise outcomes for children and families (Cowley et al. 2013). In this study health visitors were asked to reflect on how the enhanced, structured home visiting service had influenced their relationships with children and families.

4.11 The majority of health visitors were positive that the increased home visiting offered a good opportunity to build trusting relationships with children and families.

I think, the biggest difference that I feel is that we've been able to establish really strong relationships with families because of the intensive visiting (H16).

4.12 However, only two health visitors felt that the changes have not had any influence on their relationships with families. For instance, one of them felt that drop-in clinics were equally useful in terms of establishing trusting relationship with families.

I think I've always had a good relationship with the families and I feel my relationships through clinics and immunisations as well enhanced that relationship. I wouldn't say just the home visits strengthen the relationship (H25).

4.13 Nevertheless, those who felt that the universal timeline had improved their relationships with children and families, also articulated some additional benefits. For instance, they felt that the enhanced service helped develop relationships and enhanced trust. This ensured that families were more open and confident to discuss sensitive issues with them. Families then saw them as first point of contact.

Another mother asked me to go and see her and I saw her this morning. And the pretext was she wanted the baby weighed. But, really and truly, what she wanted to talk about was her eight year old child who has a bowel problem. So, I was able to discuss that, his diet, the importance of developing a bowel habit. So, the mother knows you well enough, trusts you enough, doesn't think it's important enough to go to the GP, so it saves an expensive doctor appointment if she feels she can contact me and I can manage the situation (H17).

4.14 Some health visitors also added that, due to the trusting relationships they have developed with parents, parents now feel more confident to contact them by phone.

I think we get to build up a better relationship with the parents. I think that's quite important, that we do sort of, at the beginning, we do six weekly visits, which I think is really helpful to build up that relationship. And you find mums do phone quite frequently now, and I think they've got a sort of a bit of a trust in you (H18).

Engaging families with wider services

4.15 There is evidence that health visiting is instrumental to an uptake of services, especially for families who find services difficult to access (Cowley et al., 2013). It was clear in this evaluation that health visitors are now making more referrals to wider services. Nursery placements was a service that was particularly mentioned.

If you're visiting people on a more regular basis, you identify problems and you can anticipate difficulties, therefore, you can make appropriate referrals, perhaps, sooner than you might have done and that can only be a good thing. For example, I made six referrals this month to access an early nursery placement (H17).

4.16 Health visitors however, expressed the opinion that referring families for additional support has often been challenging. They felt that a more efficient system was required.

I think, there's still a lot of work needed around referral pathways (H16).

4.17 Role clarity and clear responsibilities enable staff to manage challenges around interagency or inter-professional team working (McKee and Queen, 2014). Families also benefit from professionals working together in an effective way (Barlow et al., 2008). As such, we asked health visitors to report on their experiences of professional partnership working. They felt that the enhanced service has improved their professional partnership working. They perceived that other practitioners and services are much clearer of their role.

So, if you are at say, for example, a child protection meeting and the team are drawing up a care plan, I think, we're much clearer about what our role is within that whereas before we were probably getting, sort of, a lot of blurring of roles between the agencies and, kind of, getting fitted into the care plan whereas, I suppose, now we're a bit clearer about what our role is (H16).

Health visitors' perceptions of how families understand their role

4.18 Health visitors felt that increased, structured home visiting offers the opportunity for families to know and understand their role much better. They assumed that previously most people were unclear of their role. However, they believed that the changes have helped to clarify this.

I think, because they see more of you so they're much clearer about who their named health visitor is, how to contact you and what our role is (H16).

4.19 More so, health visitors felt that families are now more knowledgeable of the services they offer.

And, I think, families are much more aware now of what to expect from the timeline so often they'll phone us up and say, oh, my baby's coming up for six months and, you know, they know that that's what they're entitled to now so, no, it's good (H16).

At the early stages, they know what you're doing. They know when you're available, and I think it's a better understanding. Although before you would say when you would be visiting and whatever, I think because of the closeness at the beginning of the visits there's maybe less anxieties with families, sort of, thinking, right, well, when is the next time the health visitor's coming out? And they don't need to worry as much. They know they can maybe leave things until you come out (H20).

Assessment and recording systems

4.20 In NHS Ayrshire and Arran, there is currently a total of eleven visits in the universal assessment timeline for core families. The first visit starts from 11-14 days, then weekly until the fifth week. The next visit in the timeline is the 6-8 weeks, which is followed by visits at 12, 16 and 24 weeks. The next two visits occur at 12 months and 27-30 months. The last visit is the preschool handover assessment contact. However, some health visitors were concerned that some of the gaps between assessment visits in the timeline were too wide apart and that seems uncomfortable for parents.

But a lot of the parents find from a year to 27 months is too long not to be seeing anybody. And I think that is quite a gap as well (H12).

4.21 Although, the health visitors are no longer involved in drop-in clinics, they felt that it would be useful to get access to children's immunisation records in order to conduct a more complete assessment of children and their families.

In some ways, because that (immunisation) was always part of our role to check that, you know, part of your holistic assessment would be to check immunisations are up to date, but now they're not even going on FACE, our electronic system. So they're not really going in the notes. So it's been sort of, sort of taken away from us and put more on the GPs, which is fine, but then we don't know people who failed to attend (H5).

4.22 Almost all health visitors raised concerns about their current electronic recording system. They felt that a much more efficient and less laborious system will be helpful to compliment the timeline.

I am constantly aware of the numbers of visits you've got in one day and it's not just that, the electronic records take up quite a lot of time and, of course, it's very important. You have not completed your intervention with a client until you've got your electronic record complete. You've got to have contemporaneous records (H17).

Differences in service delivery across the three areas

4.23 There were small differences in service provision across areas of Ayrshire and Arran. It appeared that some very few areas were still offering women the opportunity to attend drop-in clinics (supporting quotes withheld).

4.24 There were also some indication that some health visitors were engaging the services of skill mix and staff nurses to fulfil some of the timeline.

At the moment, we're using, sort of, skill mix to do some of the visits, some of the staff nurses are carrying out a couple of visits in the timeline (H18).

4.25 However, others pointed out that involving skill mix in the timeline does not promote continuity and consistency across the service.

I think it (timeline) has brought continuity I think, like, and within Ayrshire and Arran, you know, I think…I would hope that it would. It brings a more consistent approach to all families. However, talking to colleagues in other areas, I think some people have pulled back a bit more and have put in more skill mix and, you know, the waters are getting muddied again (H13).

4.26 This assertion was also supported by another health visitor who felt that there was a need for clearer guidelines regarding how the timeline should be operationalised.

There needs to be clear guidelines as to who does the visits. Because it's not the same, it's not the same throughout. I think it needs to be endorsed in such a way that, you know, who should be doing the visits. Because it's all over the place (H23).

Perceived impact of workload on timeline

4.27 It was clear that outcomes of the enhanced, structured home visiting service cannot be looked at in isolation without considering how the health visitors who deliver the service are coping with the demands and challenges of their current role. This also presented an opportunity to examine their belief and enthusiasm towards the programme.

4.28 A common theme amongst all health visitors was that their current caseloads limited their ability to fully fulfil the demands of their role.

I mean as I say, I do like the timeline and I do think it would work. I think you need smaller caseloads to be able to do it properly and do all the other things as well (H12).

4.29 They added that even though they are now identifying more concerns, their caseloads have made it nearly impossible to support families the way they would have expected. This appeared to have compelled some health visitors to refer more clients to wider services as explained by one participant below.

I mean, to be honest, we've not got a huge deal of time for targeted intervention work. We would tend to ask a support worker, or maybe another service, to do that, like Barnardo's, if there was maybe housing issues. It's like an ongoing assessment, so you're able to pick it up quicker, really. And that's what we're looking for with prevention, and early intervention. But actual pieces of work, probably I would need to refer to somebody else, because we can't do the timeline, and do specific pieces of work, within the size of the caseload (H21).

4.30 Considering plans to increase the number of health visitors in NHS Ayrshire and Arran by 50, health visitors were asked to comment on what they would be able to provide that they are currently unable to, due to workload constraints. They all agreed that the proposed increase in the number of health visitors will ensure that more opportunities will be available to support families.

I think we'll be able to fulfil the whole timeline, we'll be able to do all the visits. And I think our vulnerable families will have a much better service, because we'll have less of an overall caseload (H18).