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

6 Bringing them all together

Context, mechanism and outcome configuration

6.1 This chapter forms phase 3 of the realist design. It uses the findings of phase 2 (health visitors and parents) to revise the initial assumptions of the programme outlined in the logic model (phase 1). The initial logic model has been disassembled into context, mechanism and outcome (CMO) configurations/components in order to understand how the programme works in practice. For instance, contexts entail the established conditions or opportunities offered by the programme but are not necessarily worded as in the logic model. For example, "immunisation and drop-in clinics no longer part of model of care" in figure 4, evolved from "streamlining and redefining the HV role in the logic model". However, this has been made more explicit here to reflect a clearer understanding of the programme. Discussions in this chapter are based on overarching themes that emerged across health visitors and parents' findings.

Component 1: Families being supported

6.2 It was clear from both health visitors and parents that the increased, structured home visiting improves early identification of concerns and assists in tailoring support (see figure 3). Health visitors mentioned that they are increasingly providing diverse kinds of supports to children and families, including feeding and attachment support. Although most of the parents who participated in this study indicated that they did not breastfeed their children, they were nevertheless appreciative of the feeding support they received from health visitors. It is therefore not surprising that breastfeeding rates in NHS Ayrshire and Arran had increased since the enhanced service was implemented (ISD Scotland, 2014) (see appendix 6). However, the data must be treated with caution as cause and effect cannot be assumed.

Figure 3 Refined CMOs for Components 1: families being supported

Component 2: Benefits of home visiting

6.3 Although parents liked the structured, increased home visiting, however a good number of those who had previously experienced the drop-in clinics also indicated that they missed attending them because of the social support opportunities they provided. This confirms what some of the health visitors mentioned. It is likely that because there are no more drop-in clinics, some health visitors and parents found gaps in between some assessments visits a little too wide apart. This might have resulted a higher demand for phone support.
6.4 Also, there were thoughts that since health visitors were no longer immunising children, immunisation uptake rates might perhaps decrease. However, the current figures show that they have either stayed the same or increased from 2013 to 2014 (ISD Scotland, 2015) (see appendix 7). Although definite conclusions cannot be made about the rates, they still provide some reassurance that the changes have not had negative impact on immunisation rates. Nevertheless, there was strong sentiments from health visitors that getting access to immunisation records of children would enhance holistic assessment of children and families (see figure 4).

Figure 4 Refined CMOs for Components 2: Benefits of home visiting

Components 3: Trusting relationships

6.5 It was clear from both health visitors and parents that the timeline has hugely improved the rapport between them (see figure 5). Although most parents have had two or more health visitors, they felt that home visiting provided adequate time to establish new relationships. More so, it was reassuring to see more parents recognising health visitors as first point of contact on a range of issues which they would have previously sought medical attention.

Figure 5 Refined CMOs for Components 3: trusting relationships

Components 4: Health visitors' role

6.6 There was evidence that the increased, structured home visiting service has clearly defined the role of health visitors. Parents showed greater understanding of what they feel the health visitors' role is. Health visitors also felt that they are receiving more recognition from other professionals regarding supporting the needs of children and families. They feel that they now work more efficiently with other agencies. This appeared to have raised health visitors' confidence and enhanced their morale (figure 6).

Figure 6 Refined CMOs for Components 4: health visitors' role

Component 5: Systems and structures supporting implementation

6.7 The increased, structured enhanced service has hugely standardised health visiting service in NHS Ayrshire and Arran. However, there appeared to be subtle differences in the service delivery. There were also indications that some health visitors were referring more children and families to wider services as they struggled to accommodate the timeline and caseloads. Yet, most health visitors found the referral pathways challenging and this contributed to the workload pressure. The situation was not helped by the perceived laborious electronic recording system. Some health visitors also felt frustrated by not being able to access children's immunisation records from the current electronic system (see figure 7).

Figure 7 Refined CMOs for Components 5: systems and workforce development

Limitations of this evaluation

6.8 This study did not use experimental design and mainly used qualitative methods to collect data. As such, outcomes cannot be robustly linked to the activities offered by the programme.

6.9 It was practically challenging to obtain data to fully interrogate all the items identified in the initial logic model. For instance, there was no routine data available on reduction in complaint about disparity in service across areas, and it was also not feasible to ascertain this outcome qualitatively.

6.10 Nearing the later stages of the evaluation, recruitment stalled and a member of staff at the study site contacted potential participants directly and informed them about the study. It is likely that this approach led to selection bias, in that individuals with particular characteristics may be more likely to agree to participate.