1. Health visiting as a proportionate universal service Sarah Cowley 19th March 2015 2. Acknowledgements Empirical study Voice of service usersAIMS Literature review Narrative synthesis of health visiting practice Empirical study Recruitment and retention for health visiting This work was commissioned and supported by the Department of Health in England as part of the work of the Policy Research Programme. The views expressed are those of the authors and not necessarily those of the Department of Health. Presentation available to download from http://fyir.org.uk/events.htm 3. Inequalities in early childhood: proportionate universalism Giving every child the best start in life is crucial to reducing health inequalities across the life course. . . . (We need) to increase the proportion of overall expenditure allocated (to early years, and it) should be focused proportionately across the social gradient to ensure effective support to parents, starting in pregnancy and continuing through the transition of the child into primary school. . . . . Marmot (2010 p 23) Fair Society, Healthy Lives 4. Why Foundation Years? Strong, expanding evidence showing the period from pregnancy to two years old sets the scene for later mental and physical health, social and economic well- being Direct links to cognitive functioning, obesity, heart disease, mental health, health inequalities and more Social gradient demonstrates need for universal service, delivered proportionately Foundations of health: Stable, responsive relationships Safe, supportive environments Appropriate nutrition www.developingchild.harvard.edu 5. Both. . and. . not . either. . or. . Universal and targeting Need for targeted services delivered from within universal provision delivered to all Population assessment (commissioner-led) and family/individual assessment (practitioner-led) Different intensities and types of provision according to individual need Generalist health visiting and embedded specific, evidence based interventions Take into account social gradient and prevention paradox 6. Family Disadvantage Indicators No parent is in work Family lives in poor quality or overcrowded housing No parent has qualifications Mother has mental health problems At least one parent has longstanding, limiting illness, disability or infirmity Family has a low income below 60% of the median Family cannot afford a number of food or clothing items. A rise in adverse outcomes for children becomes evident when their families experience only one or two of these seven indicators Mapped to children in the Millenium Cohort Study and area to show spread across social gradient Caution: figures (next) are for explanation only: they are old (2000-09) and approximate; Primary Care Trusts (PCTs) no longer exist Family Disadvantage Indicators omit key markers, e.g. illicit drug use, domestic violence and abuse Social Exclusion Task Force (2007) Reaching Out: Think Family. Analysis from families at risk review 7. Children with no Family Disadvantage Indicators by area disadvantage (IMD 2009) Social Exclusion Task Force (2007) Think Family: analysis from families at risk review 8. Children with Family Disadvantage Indicators by area disadvantage (IMD 2009) Social Exclusion Task Force (2007) Think Family: analysis from families at risk review 9. Pre-school children: distribution across Primary Care Trusts (IMD 2009) ONS 2009 10. Number of children aged 0-5 affected in each group in each centile 65% of Children - 864,465 35% of Children - 475,164 11. Obesity prevalence and deprivation National Child Measurement Programme 2013/14 Year 6 children 11Patterns and trends in child obesity (note a similar patternis seen in Reception year)Child obesity: BMI 95th centile of the UK90 growth reference Local authorities in England 12. Prevention paradox A large number of people at small risk may give rise to more cases of disease than a small number of people at high risk High risk groups make up a relatively small proportion of the population Need to shift the curve of the gradient and distribution of need across the whole population to reduce overall prevalence Khaw KT and Marmot M (2008) 2nd edition Roses Strategy of Preventive Medicine 13. Strengths: capacity and resources across population 14. Health visitor direct input: Universal provision, delivered proportionately 15. Health visitors do not work alone 16. Wider community Neighbourhood Family Parent Child Children do not live alone (in UK) Shifting focus of attention to need Situation, resources to meet need Simultaneous assessment, prevention, intervention Bronfenbrenners (1986) concept of nested systems 17. Wider community Neighbourhood Family Parent Child Health visiting practice Focus on situation and resources needed for prevention and promotion Community and caregiver capacity1 Foundations of health1 Stable, responsive relationships Safe, supportive environments Appropriate nutrition 1www.developingchild.harvard.edu 18. Relational process; focused practice Bidmead C (2013) http://www.kcl.ac.uk/nursing/research/nnru/publications/Reports/Appendices-12-02-13.pdf Salutogenic (health creation) Person-centred Person-in- context 19. Updated Health Visitor Implementation Plan Growing the workforce Professional mobilisation Service transformation 20. Oct 2015: Commissioning of HVs shifts to Local Government DH: 4-5-6 model for health visiting 21. For families universality should mean: Universal offer of: Five mandated contacts: everyone gets this Healthy Child Programme (HCP) Service on their own terms Service journey Meet/get to know health visitor: trust relationship, partnership working relational autonomy Services delivered to all i.e., home visits (HCP) Health visiting outside home well baby clinics, groups etc, in conjunction with others (e.g. Childrens Centres) Open secret of safeguarding/child protection Cowley et al (2014) http://dx.doi.org/10.1016/j.ijnurstu.2014.07.013 22. Universal Plus: simultaneous prevention and treatment Across six high priority areas and more, e.g. Specially trained health visitors can simultaneously prevent Brugha et al 2010, detect and treat post-natal depression through listening visits Morrell et al 2009 Post-qualifying training being rolled out by Institute of Health Visiting (Perinatal Mental Health Champions) 23. Mental health Post-natal depression (PND) Early identification and treatment with listening visits Morrell et al 2009 Prevention of PND Brugha et al 2010 More relaxed mothering Wiggins et al 2005, Barlow et al 2007, Christie et al 2011 Improved mother/infant interaction Davis et al 2005, Barlow et al 2007 Special needs: Reduced childrens ADHD symptoms and improved maternal well- being, by HV working in specialist team Sonuga-Barke et al 2001 24. Universal Partnership Plus Maternal Early Childhood Sustained Home Visiting (MECSH) Designed to capitalise on what is known about successful programmes Sufficient intensity and duration: home visits + groups Strengths based practice using family partnership model - FPM (Davis et al 2002) Two generational (parent and child) and multi- faceted/community based Highly skilled professionals And to add in: Support and develop existing, generic service Shift the curve by targeting worst-off 20% Kemp et al ( 2011) Archives of Disease in Childhood 96:533-540. 25. Health visitor research programme Literature - evidence of benefits, if sufficient staff, skills, knowledge Health Visitors desire to make a difference for children and families Parents desire to be known, listened to and ease of access Shared desire for: Others to value their knowledge and contribution Respectful, enabling relationships Flexible service (varied intensity + type, e.g. home visits and centre-based) to match need 26. What is needed? Organisational support Conflicting demands Population needs (e.g., KPIs, targets) vs. individual/family needs Sufficient time Staffing levels Equipment for job Sufficient skills Education: For qualification/pre-registration health visitor programme Continuous professional development 27. Revenue costs Funding 1999/2000 2001/02 millions (actual) 2002/03 2004/05 millions (actual) 2005/06 2007/08 millions (actual) 2008/09 2010/11 millions (estimated) Sure Start Local Programmes 141 840 1074 838 Childrens Centres 0 13 656 2205 Health visitors 965 965 900 840 totals 1106 1818 2630 3883 Source: Audit Commission (2010) Giving Children a Healthy Start 28. Whole time equivalent (WTE) health visitors employed in England (1988) 1998-2014 10,680 10,020 10,070 10,050 10,046 10,190 9,912 9,999 10,137 9,809 9,376 9,056 8764 8519 8017 7941 8385 9550 10800 7,500 8,000 8,500 9,000 9,500 10,000 10,500 11,000 11,500 12,000 1988 1998 2000 2002 2004 2006 2008 2010 2012 2014 WTE health visitors Nov 2014 = 11,239 Incl. 501 non-ESR Target = 12,292 WTE (May 2015) ESR = NHS electronic staff record Source: Information Centre for Health and Social Care * 29. Sufficient time What is appropriate level of staffing? Family Nurse Partnership caseload = 25 families Starting Well = 80-85 families (including skillmix) Typical HV caseload = 400+ families, up to 1000 Funding model Cowley 2007, Cowley and Bidmead 2009 Recommends range according to levels of deprivation, between 100 and 400 children per health visitor, not accounting for skillmix (consensus papers) Research about skillmix/teamwork Cowley et al 2013 Scarce, not linked to outcomes Issues about referral, delegation, specialisation 30. Skills and knowledge Health visitor programme: Open only to registered nurses or midwives 45 programmed weeks 50% theory, 50% practice, i.e. 22.5 weeks in each More education needed for. . . . Community development/public health practices, multi-agency/multi- disciplinary engagement, need for more knowledge about breast feeding and immunisation, better preparation to promote home safety and unintentional injury, more/better skills in dealing with post-natal depression and mental health, better understanding, knowledge and skills for obesity prevention, health visitors should be better equipped to deal with skillmix, including delegation, support to develop more skilful, culturally competent practice with seldom heard groups, including BME populations and those experiencing current major life problems such as insecure housing or seeking asylum, sensitivity and skills in enabling disclosure of e.g domestic violence, hidden needs, able to develop authoritative practice in complex needs, e.g. in child protection situations . . . . . 31. How to get sufficient skills? Post-qualifying continuing professional development Better preceptorship for new/recently qualified and updates for all Cascade training through Institute of Health Visiting: Perinatal mental health Infant mental health Domestic violence and abuse Etc., etc Pre-registration programme The current 45-week programme is over-full Longer/different approaches needed All options need to be on the table, including a wider entry gate and direct entry degree or Masters programmes 32. Health and Inequalities: focus on the Foundation Years Known importance of Caregiver and Community Capacities Foundations of Health Biology of Health Emerging understandings: what is necessary (required) for child development what is foundational: ie, other elements will not work without it how to measure foundations and requirements (assets/capacity) which outcomes are appropriate and helpful to measure connections that exist between problem-based (prevention) and capacity-building (promotion) approaches how to delineate attribution www.developingchild.harvard.edu 33. Policy recommendations Marmots second revolution for the early years: increase overall expenditure, focused proportionately across gradient Build on health visiting plan successes dont lose the benefits of 2011-15 in transfer to local government Enabling sufficient health visiting time, skills, organisation = better outcomes (six high impact areas) flexible/acceptable service both population health needs and individual families 34. Thank you! sarah.cowley@kcl.ac.uk http://fyir.org.uk/events.htm 35. Why Health Visiting References Reports on NNRU website: http://www.kcl.ac.uk/nursing/research/nnru/publications/index.aspx Bidmead C (2013) Health Visitor / Parent Relationships: a qualitative analysis. Appendix 1, in Cowley S, Whittaker K, Grigulis A, Malone M, Donetto S, Wood H, Morrow E & Maben J (2013b) Appendices for Why health visiting? A review of the literature about key health visitor interventions, processes and outcomes for children and families. National Nursing Research Unit, Kings College London Cowley S, Whittaker K, Grigulis A, Malone M, Donetto S, Wood H, Morrow E & Maben J (2013a) Why health visiting? A review of the literature about key health visitor interventions, processes and outcomes for children and families. National Nursing Research Unit, Kings College London Cowley S, Whittaker K, Grigulis A, Malone M, Donetto S, Wood H, Morrow E & Maben J (2013b) Appendices for Why health visiting? A review of the literature about key health visitor interventions, processes and outcomes for children and families. National Nursing Research Unit, Kings College London Donetto S, Malone M, Hughes, Morrow E, Cowley S, J Maben J (2013) Health visiting: the voice of service users. Learning from service users experiences to inform the development of UK health visiting practice and services. National Nursing Research Unit, Kings College London Whittaker K, , Grigulis A, Hughes J, Cowley S, Morrow E, Nicholson C, Malone M & Maben J (2013) Start and Stay: the recruitment and retention of health visitors. National Nursing Research Unit, Kings College London Policy+ 37: February 2013 - Can health visitors make the difference expected? http://www.kcl.ac.uk/nursing/research/nnru/Policy/policyplus.aspx Published papers Cowley S, Whittaker K, Malone M, Donetto S, Grigulis A & Maben J (2014) Why health visiting? Examining the potential public health benefits from health visiting practice within a universal service: a narrative review of the literature. International Journal of Nursing Studies (online/early view) http://authors.elsevier.com/sd/article/S0020748914001990 Donetto S & Maben J (2014) These places are like a godsend: a qualitative analysis of parents experiences of health visiting outside the home and of childrens centres services Health Expectations (online/earlyview) doi: 10.1111/hex.12226 http://www.kcl.ac.uk/nursing/research/nnru/publications/index.aspx 36. References Audit Commission (2010) Giving Children a Healthy Start London: Audit Commission Bronfenbrenner U. Ecology of the family as a context for human development: Research perspectives. Developmental Psychology 1986. 22: 6, 723-742. Barlow J., Davis H., McIntosh E., Jarrett P., Mockford C., & Stewart-Brown S. (2007) Role of home visiting in improving parenting and health in families at risk of abuse and neglect: results of a multicentre randomised controlled trial and economic evaluation. Archives of Disease in Childhood 92, 229-233. Brugha TS, Morrell CJ, Slade P & Walters SJ (2010). Universal prevention of depression in women postnatally: cluster randomized trial evidence in primary care. Psychological Medicine, 41: 739-748 Christie J, Bunting B (2011) The effect of health visitors postpartum home visit frequency on first-time mothers: Cluster randomised trial. International Journal of Nursing Studies 48: 689702 Cowley S (2007). A funding model for health visiting: baseline requirements part 1. Community Practitioner. 80 (11): 18-24; Impact and implementation part 2. Community Practitioner. 80(12): 24-31 Cowley S and Bidmead C (2009) Controversial questions: what is the right size for a health visiting caseload? Comm Practitioner, 82 (6): 9-23 Davis H., Dusoir T., Papadopoulou K.et al. (2005) Child and Family Outcomes of the European Early Promotion Project. International Journal of Mental Health Promotion 7, 63-81. Kemp L, Harris E, McMahon C, Matthey S, Vimpani G, Anderson T, Schmied V, Aslam H, Zapart S. (2011) Child and family outcomes of a long-term nurse home visitation program: a randomised controlled trial. Archives of Disease in Childhood 96:533-540. Rose G (2008) (2nd edition with commentary by Khaw KT and Marmot M) Roses Strategy of Preventive Medicine. Oxford University Press Marmot, M., Allen, J., Goldblatt, P., Boyce, T., McNeish, D., Grady, M., et al. (2010) Fair society, healthy lives: The Marmot Review - Strategic review of health inequalities in England post-2010. London: The Marmot Review Morrell CJ, Warner R, Slade P, Dixon S, Walters S, Paley G, Brugha T (2009). Psychological interventions for postnatal depression : cluster randomised trial and economic evaluation. The PONDER trial. Health Technology Assessment 13, 1176. Shonkoff JP (2014) Changing the Narrative for Early Childhood Investment JAMA Pediatrica. 168(2):105-106. Social Exclusion Task Force (2007) Think Family: analysis from families at risk review. London, Cabinet Office Sonuga-Barke EJ, Daley D, Thompson M, et al (2001) Parent-based therapies for preschool attention-deficit/hyperactivity disorder: A randomized controlled trial with a community sample. Journal of the American Academy of Child & Adolescent Psychiatry 40(4): 402-408. Wiggins M, Oakley A, Roberts I, Turner H, Rajan L, Austerberry H, Mujica R, Mugford M, Barker M (2005) Postnatal support for mothers living in disadvantaged inner city areas: a randomised controlled trial. Journal of Epidemiology and Community Health. 59: 288-295