Universal Health Visiting Pathway evaluation: phase 1 report - routine data analysis - implementation and delivery

Introduction

The early years of life have a profound impact on an individual's long-term health and wellbeing. Children's emotional, cognitive, linguistic, social and physical development, including the bond they form with parents, can significantly affect their future health and wellbeing as adults.^[1] Investing in early years therefore creates opportunities for the future lives of children.^[2]

In 2013, the Chief Nursing Officer's Directorate, Scottish Government, undertook a scoping exercise of health visiting practice in Scotland. The findings demonstrated that there was a significant degree of variation across the service in terms of assessment, resources and visiting patterns being delivered by health visitors to families in Scotland. A refocused approach to health visiting was published by the Scottish Government in 2013. The changes took into account the changing policy landscape relating to the early years and children and families, and sought to ensure that workforce capability and capacity would be equipped to successfully deliver these policies. Following substantial investment in the service, the Universal Health Visiting Pathway (UHVP) was introduced in 2015.^[3]

The Universal Health Visiting Pathway

The UHVP refocuses the role of the health visitor and includes changes to caseload weighting and management; intervention delivery; education, training and resources; and visiting patterns. The UHVP sets out a structured home visit programme for all families,^[3] which includes an increased number of visits from what was previously delivered. All families are entitled to receive at least eleven routine visits from health visitors, eight within the first year of life and three child health reviews between 13 months and 4-5 years. Additional support is also provided according to the level of need in line with a proportionate universalism approach, where the service is provided to all families, but more of the service is provided to those with a greater need. The home visits begin from pre-birth until the child is five years old (or enters school).

The Evaluation of Health Visiting in Scotland

Following the review of health visiting and introduction of the health visiting pathway an evaluation of the service was commissioned by the Scottish Government in 2018. This evaluation of the Universal Health Visiting Pathway will be conducted in two phases. Phase 1 commenced in 2018 and will provide baseline outcomes data and early learning in regard to the processes of implementing the Health Visiting Pathway. Phase 2 will provide evidence in regard to the outcomes that health visiting is contributing towards and to provide further information for the development of the processes health visitors use. The evaluation is comprised of five key components:

• Review of the health visiting logic model and associated desired outcomes^(a)
• Analysis of the routine data collected as part of the health visiting role
• Survey of parents and health visitors
• Case note review
• Qualitative research with parents, health visitors and stakeholders

Aims of the evaluation

The aim of this study is to examine the extent to which the UHVP is implemented and delivered across Scotland and to assess any associated impacts. To achieve this, a robust mixed-methods realist evaluation proposal has been developed to understand 'what works for whom, why and in what circumstances'.

The key aims of the evaluation are:

1. to examine what elements of the UHVP are being implemented in which areas, when and how.

2. to determine the extent to which the UHVP is implemented and delivered across Scotland and assess any associated impacts over the longer term.

3. to identify and explain to what extent recommendations to fill gaps in the UHVP are delivered and their impacts on services, staff and children and families.

Reporting of the evaluation

The following four reports have been produced as part of the Phase 1 evaluation:

• Phase 1 Report – Primary Research with Health Visitors and Parents and Case Note Review (Published)
• Phase 1 Report – Routine Data Analysis – Workforce (Published)
• Phase 1 Report – Routine Data Analysis – Outcomes (Published)
• Phase 1 Report – Routine Data Analysis – Implementation and Delivery (this report)

Analysis of the routine data

As a key part of their role health visitors are required to routinely collect data about the families and children they visit over the course of the first five years of the child's life. The routine data gathered provides an invaluable source of evidence about children in their earliest years in Scotland.

At present, national data is collected at the four formal assessment points via the Child Health Surveillance Programme (CHSP);^(b) however, the only record of any further visits is within the clinical notes completed by the health visitor. Data for the 6-8 week and 27-30 months assessments have been collected since 2013, and data for the 13-15 month and pre-school assessments have been more recently added.

Alongside the CHSP data, other data sources, such as workforce data, are collected by health boards to monitor the health visiting workforce employed to deliver the Universal Health Visiting Pathway. Data collected in educational settings and by social work services in Scotland were also considered as part of this evaluation. The statistical analysis plan for the routine data process evaluation analysis was published in 2020.^[4]

Implementation and delivery - Routine Data Analysis

This report presents the findings of the analysis of data relating to the implementation and delivery of the Universal Health Visiting Pathway in Scotland. It examines the timing of the delivery of the child health reviews, changes to health plan indicator allocation and identification of developmental concerns. In addition, routine data are also used to explore the extent to which the guidance set out in the Universal Health Visiting Pathway has been implemented; this includes:

• all child health reviews being delivered by a qualified health visitor, and
• taking place in the child's home, as well as
• the use of the Ages and Stages Questionnaire (ASQ 3) in developmental assessments.

Research questions

The full research context is set out in Phase 1 Report - Primary Research with Health Visitors and Parents and Case Note Review. The specific intended outcomes of the UHVP have also been set out in a programme logic model found in the above-mentioned report. In this report, the following specific research questions are addressed:

• What is the extent to which the universal child health review elements of the pathway are being delivered, the equity of these contacts, and the extent to which this varies by health board?
• What is the extent to which child and family needs are being identified in a timely manner?