Universal Health Visiting Pathway in Scotland: pre-birth to pre-school

Introduction

The Early Years have a profound impact on an individual's future experience of health and wellbeing. Health professionals, particularly Health Visitors, have a vital role to play in supporting children and families in the first few years of a child's life.

Building on the collaborative working of several national groups and lessons learned from other relevant activities such as Family Nurse Partnership ( FNP), the aims of this document are to provide a consistent approach to Health Visiting roles and services across Scotland and to provide guidance to practising Health Visitors. It is intended to be a supportive tool to underpin Health Visitors proactive interactions with families. While clearly specifying expectations of the Health Visitor role and services, the pathway defines and enhances Health Visitors responsive way of working with parents and their children.

A New Look at Hall 4 (2011) ^[1] sets out the way forward for the successful delivery of Health for All Children (Hall 4) in the early years. This now requires to be delivered in the context of duties and provisions set out in the Children and Young People (Scotland) Act 2014 ('the Act'), supporting guidance and the Getting it Right for Every Child ( GIRFEC) policy. The programme set out in Hall 4 can be delivered by any member of the primary care or wider Child Health Support Team, including General Practitioners, Staff Nurses, Early Years Support Workers or Health Visitors. This document and Universal Health Visiting Pathway emphasises the Health Visitor's specific unique contribution to achieving Hall 4, compliance with the Act and delivery of the GIRFEC Policy and building on this, highlights their core and wider role through home visiting which focuses on relationship building with the family; ensuring that families' needs are appropriately assessed and responded to in a person-centred and supportive way.

Evidence demonstrates the importance of prevention, early identification and intervention throughout the early years of life. Health Visitors have, and always have had, a significant public health role to play in relation to individuals, families and communities by providing critical support to all children under five years of age ^[2] .

A scoping exercise across NHSScotland, undertaken in 2013 by the Chief Nursing Officer's Directorate, Scottish Government, demonstrated significant variation in the services, assessments, resources and visiting patterns offered by Health Visitors to families in Scotland. In conjunction CEL13 (2013) ^[3] published by Scottish Government in 2013 outlined the requirement for NHS Boards to refocus Health Visitor's important role within early years and address variation by ensuring that through education, and refocused approaches to Health Visiting, services and professional practices are provided consistently to all children under 5 and their families throughout Scotland. The Children and Young People (Scotland) Act 2014 has significant implications for Health Boards particularly in relation to the delivery of a Named Person service for preschool children that will largely be made available to children and families through health visiting services.

Fundamental to these changes are: the utilisation of public health approaches in responding to all families; an emphasis on reducing inequalities by increasing access to appropriate interventions; responding to vulnerable groups and importantly, ensuring that the right number of Health Visitors are in the right place, with the right support available to them to enhance their professional practice.

The development of this Universal Health Visiting Pathway, and its underpinning programme of work, has been supported by two years of collaboration between Scottish Government, Executive Nurse Directors and Territorial NHS Boards in Scotland. Four working groups and associated sub groups have reviewed the Health Visitor role; interventions; visiting patterns; education; resources; caseloads; evidence (including the required outcomes to be measured) and national evaluations of the new programme required to be undertaken over forthcoming years ( Appendix 1 ).

This Pathway underpins and guides the foundation of the refocused Health Visitor role for NHSScotland and integrates the Named Person role. It should be considered alongside work undertaken on caseload weighting and management, increased health visitor training, investment and practice development. It is central to the implementation of the Children and Young People Scotland (Scotland) Act 2014 ^[4] and sits alongside Health Boards' local Health Visitor Implementation Plans and wider workforce planning for early years.

All Practice Teachers and Health Visitors are central to this programme's successful implementation and all have a vital role to play in refocusing roles and in providing early and consistent support to families in Scotland.

The Pathway

The Pathway presents a core home visiting programme to be offered to all families by Health Visitors as a minimum standard. Along with these core home visits Health Visitors exercising the function of a Named Person on behalf of their Health Board will be required to be available and responsive to parents to promote support and safeguard the wellbeing of children by providing information, advice, support and help to access other services. The Pathway is based on several underlying principles. These are:

• Promoting, supporting and safeguarding the wellbeing of children
• Person-centeredness
• Building strong relationships from pregnancy
• Offering support during the early weeks and planning future contacts with families
• Focusing on family strengths, while assessing and respectfully responding to their needs.

The programme consists of 11 home visits to all families - 8 within the first year of life and 3 Child Health Reviews between 13 months and 4-5 years.

Spanning the antenatal to pre-school period, it ensures the opportunity for Health Visitors, children and their parents to truly "connect"; and provides the platform for ensuring the unique family/Health Visitor relationship, pivotal to providing a gateway to other levels of Health Visiting provision and to promoting, supporting and safeguarding the wellbeing of children. This early establishment of the family/Health Visitor relationship provides Health Visitors with a sound foundation for their role as the Named Person from birth ^[5] .

The proactive and health promoting focus of Health Visiting means that, particularly in the mid to later phases of pregnancy and having a new baby, services reach out to parents who may not initially have engaged with services. This way of working can potentially enhance the uptake and use of services in response to changing family circumstances. This orientation of practice will help to reduce health inequalities by responding to the needs of vulnerable and seldom heard families who require (ongoing) additional support in response to a range of special needs arising from social disadvantage or disability.

To get to know the family, the Health Visitor needs to first gain access to the family at home. Throughout this pathway and in line with the National Parenting Strategy the terms family and 'parent/carer' is used to refer to a much broader range of primary caregivers ^[6] . So both mothers, fathers and all carers involved in the lives of children and young people should be considered in the unique family/Health visitor relationship. Health Visitors holistic work with families allows the parent to get to know the Health Visitor. Ideally then a range of activities, including assessing and onward referral, ongoing availability, reciprocal exchange and collaborative interaction, leads to a situation in which parents understand and have confidence in the service, are able to express their needs and accept referrals, or initiate further contact as needed.

The pathway is based on the best available evidence which indicates that all visits should be undertaken by a Health Visitor in the home. Professional judgement should be used to assess where this is not appropriate, such as in cases / suspected cases of domestic abuse. Particular attention should also be given to vulnerable groups such as Looked After Children, homeless families or families where one or more parent is in prison or is or has been involved with criminal justice services This should also include parents who have a history of violence, substance misuse or concerns around mental health.

Specific reference is made at certain points within the pathway to the use of routine enquiry and or assessment for mental health and wellbeing. It is expected that in addition Health Visitors utilise all assessments and tools consistently at multiple points along the pathway according to judgement and need.

Families enrolled on the Family Nurse Partnership Programme should also receive the core elements of the pathway.

The final column in the pathway sets out initially anticipated national and local outcomes. The precise nature of these outcomes and data / information to be gathered both nationally and locally is still to be finalised which will inform national work on evaluation to be undertaken.

Health Plan Indicator

The national Health Plan Indicator ( HPI) has been redefined to include an emphasis on wider family health. This is listed on page 8 of the guidance and set out below:

Health Plan Indicator Definition

An additional HPI indicates that the child (and/or their carer) requires sustained (>3 months) additional input from professional services to help the child attain their health or development potential. Any services may be required such as additional HV support, parenting support, enhanced early learning and childcare, specialist medical input, etc.

Child Health Reviews

The document contains guidance and data sets for the two additional Child Health Reviews ( CHRs) to be undertaken at 13 months and before starting school. The nationally recommended tool for use at all CHRs across Scotland is the Ages and Stages Questionnaire ( ASQ 3). ASQ 3 is the mandated tool within the Family Nurse Partnership Programme. Other tools may wish to be utilised according to professional judgement and these are also listed within this document and should be used in conjunction with the 27-30 Month Guidance.

The visit at 6-8 weeks is a home visit which is in addition, but complimentary to' the review undertaken by General Practitioners at 8 weeks in the surgery or clinic. Completion and return of the Child Health Surveillance Programme form maybe a joint General Practitioner/Health Visitor responsibility in line with local arrangements.

Consideration should be given to sharing information in the interest of a child's wellbeing. This will be a statutory duty for Named Person service providers and relevant authorities including the health boards when Parts 4 and 5 of the Children and Young People (Scotland) Act are commenced (anticipated August 2016). After following due process in the Act including seeking the views of the child and normally the parent, sharing of information to promote, support or safeguard a child's wellbeing with or by a child's Named Person service will be a duty even where there is a duty of confidentiality hence consent to share relevant and proportionate information in this context will not be required and if sought and refused could potentially damage the HV/parental relationship.

In relation to the Child Health Review prior to school entry the national Child Health System will be arranged to accept a review of any child aged 4 or 5 to allow Health Visitors to decide when this review is best undertaken depending on when the child starts school.

The Evidence

There is compelling evidence that Health Visitors can have a positive impact on child and family health ^[7] but their effectiveness depends on practising in particular ways. Successful Health Visiting relies on:

• Organising Health Visiting Services to support best practice
• Delivering proven programmes and interventions to promote health and well-being and
• Having a suitably skilled and trained workforce.

Robust analysis of more than 30 years of research ^[8] shows that to improve parents' experience and uptake of services, Health Visiting needs to have a strong orientation towards practice and service delivery which is characterised by the following:

• Adopting a 'salutogenic' approach, ( i.e. health-creating), being proactive; identifying and building strengths and resources (personal and situational) and being solution-focused
• Demonstrating a positive regard for others, ( i.e. human valuing), through keeping the person in mind and shifting (the Health Visitors') focus to align with parents' needs; recognising the potential for unmet need and actively seeking out potential strengths
• Acknowledging the person-in-situation, ( i.e. human ecology), through a continuing process; always taking account of the individual, their personal and situational circumstances, whether acting in the client's space, the community or the workplace.

This strong practice orientation is underpinned by a 'triad' of interconnected core practices such as:

1. Development of the Health Visitor-parent relationship

2. Home visits and

3. Needs assessment by the Health Visitor.

Research demonstrates that these 3 core practices operate together as a single process and in so doing form the basis of 'best practice' in Health Visiting Services.

The expectation of this new Health Visiting Pathway is that because of effective relationship building (underpinned by appropriately delivered training and ongoing Health Visitor assessment), the family remains at the centre of each home visit.

Acknowledging that Health Visiting remains a specialist role that pivotally continues to involve ongoing assessment and professional judgement, the Health Visiting Pathway clearly emphasises the unique opportunity afforded by home visiting and its enhancement of the Health Visitor's key role in assessing the wider context of family and community life and circumstances.

Guidance provides broad details about the purpose of each visit; the tools to be used and anticipated outcomes for the child and family. With this responsiveness in mind Appendix 4 contains useful "tools", providing links to resources and evidence about what works to support this new orientation to practice ^[9] . While these cannot substitute face-to-face supportive discussion between the family and their Health Visitor, it is hoped that they will enhance the building of the health creating relationship and contribute to securing the foundation for family support throughout the early years.

This document will be reviewed in 2018 via the National Children, Young People and Families Nursing Advisory Group.