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

7 Conclusions

What worked well?

7.1 This evaluation yielded insights into how the enhanced health visiting practice is influencing outcomes for children and families. It also illuminated the difference it is making to health visiting practice in NHS Ayrshire and Arran. Overall, health visitors were almost universally positive about the universal assessment timeline and acknowledged the value it has added to their practice. Parents recognised the change in service and were extremely positive about the current support they received from health visitors.

7.2 Parents reported that the universal timeline improves rapport and enhances trusting relationships with health visitors. A very good number of them indicated that they have contacted their health visitors for support by phone because of the good relationship they have developed with them. Although this does not appear to be different from what was available to parents in the previous service, but what is peculiar was the perceived frequency of phone contacts with the current service.

7.3 Parents reported that their health visitors have been instrumental in terms of assisting them to access wider services both for themselves and their children. Health visitors also reported the changes have improved early engagement with services for families. Engaging children and families with nursery services were particularly highlighted by both parents and health visitors.

7.4 Parents also reported that aside from the support health visitors provided to their children, the current service ensured that their own health and wellbeing also received more attention. Support to deal with postnatal depression was particularly mentioned.

7.5 Health visitors reported that their roles are now much more defined. They believed this has enhanced their professional partnership working and they emphasised that other agencies are much clearer about their role and the services they offer.

7.6 Health visitors reported that an increasing number of families recognised them as first point of contact in various aspects of their health, wellbeing and development. There were some evidence from parents to affirm this assertion.

7.7 Health visitors reported that the universal assessment timeline has empowered them in terms of early identification of concerns, even amongst some families who would previously been considered as core families.

What may need further consideration?

7.8 Both parents and health visitors indicated that gaps between some assessment visits in the timeline were too wide apart.

7.9 Health visitors however, were concerned about referral pathways. They felt they were cumbersome. More so, as they currently identify more concerns, they viewed this as a significant challenge of the enhanced service.

7.10 Almost all parents have had more than one health visitor. However, many reported that this had little or no bearing on the support they received.

7.11 Health visitors universally acknowledged that increased home visiting has been challenging and reported that they struggled to fulfil the entire timeline. It appeared that some areas involved staff nurses and skill mix to fulfil the timeline. Other areas also operated drop-in clinics albeit in a limited fashion.

7.12 Although parents liked the home visiting, a number of them also missed the drop-in clinics. This was also the case for health visitors. Parents valued the peer support that that the drop-in clinics used to provide and emphasised the importance of social support from other parents.

Recommendations

For NHS Ayrshire and Arran

1. Provision of clear and less cumbersome guidance on referral pathways would be beneficial to health visitors.

2. Health visitors would benefit from clear guidance as to who does the visits at each stage in the universal timeline.

3. A robust electronic recording system, which is less time consuming but is accessible from the field, would be useful for health visitors.

4. It would be useful for health visitors to have access to children's immunisation records to enable a more holistic service to be provided to children and families.

5. It would be beneficial for the timeline to consider integrating weighing of babies on a more regular basis.

For the nationwide implementation

1. The number of health visitors should be adequate to ensure appropriate caseloads for a more effective delivery of the enhanced service across Scotland.

2. Clear referral pathways should be developed as health visitors are likely to identify more children or parents with additional support needs.

3. The availability of additional support services should be monitored in case more are required to deal with an increase in referrals.

4. Adequate and timely phone support should be built into the service provision. The demand for this might increase, especially as parents were concerned about wider gaps between assessment visits and were also unable to access drop-in clinics.

5. Training and refresher programmes should be made available to health visitors, possibly before the nationwide roll-out of the enhanced service, in subjects such as neurodevelopment, attachment and strength-based skills.

For nationwide evaluation

1. Collection of robust, standardised data is essential to any evaluation. A robust electronic recording system, which captures a range of outcome data and which is accessible from the field should be considered.

2. Collection of data on the following processes and outcomes should be considered:

a. parents' and health visitors' experiences of the service;

b. relationships and degree of trust between the parents and health visitors;

c. additional breastfeeding rates at 4 or 6 months at the health board level;

d. how the enhanced service impacts on other services (e.g. nurseries, primary care, social work, speech and language services);

e. number of parents and children with additional support needs identified;

f. demographics of parents and children ( to see whether the programme is addressing health inequalities);

g. number of interactions (e.g. phone calls) outside the home visits;

h. self-management of common problems and conditions.

Final concluding statement

7.13 NHS Ayrshire and Arran's model of the enhanced health visiting service 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.