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Funding restraint means health visiting services will need to integrate

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From the first of this month responsibility for commissioning a range of child public health services including health visiting and family nurses transferred to councils.

While the shift has been welcomed within public health and wider local government, healthcare professionals fear potential job cuts and service reductions now councils have taken over from the NHS.

Their concern is not surprising given plans to slash £200million from local authority public health budgets in 2015-16 and fears of further reductions in subsequent years; councils themselves admit they face a challenge.

Local authorities and partners have spent the past year planning the initial “lift and shift” of the 0-5 Healthy Child Programme from NHS England control, attempting to straighten out complexities relating to information sharing and unpicking budgets.

Debbie Barnes, director of children’s services at Lincolnshire County Council, told LGC one of the key problems has been the fact NHS services tend to be commissioned around GP practices while councils commission for the populations within their boundaries.

Nevertheless she is among those who see the move as a “huge opportunity” to develop a more cohesive approach that brings together child health with early years and a whole range of other services linked to healthy living including housing, benefits, employment and leisure.

 “People are looking at different arrangements but without a doubt everybody is looking at how we can re-commission services differently in the future,” she says.

This will include looking at creating even closer links between services like children’s centres and health visiting and health visiting and school nursing services, which already fall within councils’ remit.

“If you started from scratch would you have a health visitor working with 0-5s and then a different school nurse working with 5-16? The challenge is to come up with a more cohesive model,” says Barnes, who believes there are opportunities to cut duplication and make savings.

For many like Dr Bruce Laurence, director of public health for Bath and North East Somerset, the first priority has been to ensure services move across safely and the most vulnerable children, such as those on child protection plans, are not lost amid the change.

“There’s been a real sense of making sure we don’t screw things up in transition,” he says. “I don’t want to do anything immediately and want the workforce to know we’re not looking to make changes just for the hell it. But once it’s in safely, there are things we can think about.”

Councils working with their local clinical commissioning groups will now control pretty much “all of the child health world”, he points out and this is a real chance to streamline services and perhaps “use workers in different ways”. That may well include looking at the “skill mix” in the health visiting service.

Such comments are unlikely to reassure the existing workforce, which has “serious concerns” about the future, according to Dave Munday, professional officer and lead on health visiting for the union Unite, which includes the Community Practitioners and Health Visitors’ Association.

“You don’t save £200million by buying a few less paper clips or doing a bit less printing,” he says. “Where you get £200million savings is by making people redundant. Ultimately that has a serious impact on services.”

He cites the example of one council in the Yorkshire and Humber region which has just put 0-19 health services out to tender with a maximum budget of £4.8million, despite the fact the current service costs over £6million.

Health visitor numbers have swelled in recent years thanks after the last government made it a priority, setting a target to expand the health visitor workforce by 4,200 over the course of the parliament (see box).  The fear is the profession will now be seen as an easy target, which would be “excessively short-sighted”, says Munday.

Health visiting comes home – a brief history of the profession

The concept of a ‘health visitor’ originated in Manchester in the mid-nineteenth century. The Ladies Sanitary Reform Association, formed in 1862 in response to the high infant mortality rate in the poorer districts of Manchester and Salford, began employing women to visit the homes of poor women to advise on issues such as hygiene and child welfare.

The title of health visitor began to be used in the city in the late 19th century, by which point the women were being paid a salary by local government. This practice spread around the country so that by 1917 mothers across the country could expect to receive a visit following the birth of their child, funded by the local council.

In 1945 it became a requirement that health visitors also be registered as nurses, a requirement that continues to this day. In practice this now means new health visitors must complete a three-year nursing degree plus a further year’s training to qualify.

In 1974 health visiting moved from local authority control to the NHS. Disinvestment, particualrly between 2000 and 2010 saw their numbers fall to record lows but five years ago the coalition government announced it would expand the workforce by more than 50%, equivalent to an additional 4,200 full time equivalent health visitors.

This target was narrowly missed. Provisional figures from the Health and Social Care Information Centre reveal there were 12,077 whole-time equivalent health visitors in post in March this year. This is 3,985 more than in May 2010. However, success was variable with big cities, including London, Birmingham and Manchester, reportedly still struggling with large gaps in their workforce.

Guidance from the Department of Health has been somewhat changeable on health visiting requirements, says Dominic Harrison, director of public health at Blackburn with Darwen.

“I think the view now in local government and elsewhere is you shouldn’t be really insisting on number of x, y, z professionals, you should be insisting on the achievement of x, y, z outcomes,” he says.

“Many local authorities take the view we will always need some version of the health visitor role but whether we need all the 0-5 spend to be on health visitors is debatable.”

In his patch the council and partners are looking at a complete re-design of children’s and public health services for 0-25-year-olds.

“We have a picture of our total investment for this population and are going back to first principles to decide what outcomes we want and re-design this investment working with our clinical commissioning group,” he says.

One area they are keen to focus on is the prevention of “adverse childhood experiences” shown to damage wellbeing into adulthood.

“A very large percentage of spend and distress in children’s service relates to drug, alcohol and mental health problems in parents yet a large percentage are detectable and preventable,” says Harrison.

Councils do recognises the value of a universal service that is in touch with every child born on their patch, says Dr Virginia Pearson, director of public health at Devon County Council and lead for the 0-5 transition for the Association of Directors of Public Health.

0-5 public health services

Universal service – the national service specification for health visiting stipulates that all children should have five reviews in the first two-and-a-half years to monitor their progress towards expected development goals. These reviews have been mandated for 18 months from 1 October to ensure stability during the transition period. The guidance recommends these reviews are carried out by qualified health visitors. Children and parents identified as requiring additional support receive this as part of the universal plus service.

Family nurse partnership - The Family Nurse Partnership (FNP) is a voluntary home visiting programme for first time young parents aged 19 or under. A specially trained family nurse visits the young parent regularly, from early in pregnancy until the child is two years old. It was developed in the US and has been adapted for a UK cohort. However, a recent study questioned its effectiveness, finding no evidence it had reduced smoking rates amongst monthers or the number of subsequent pregnancies amongst the cohort when compared to those receiving a regular health visiting service.

But inevitably every authority will be looking very closely at spending and value for money. Given the anticipated scale of cuts, some with family nurse partnership schemes in place may well wonder if they can afford to continue this intensive, targeted and expensive work over and above universal health and support services, she says.

While most will be reluctant to “go back on all the good work” to boost health visitor numbers, she admits it will difficult to deliver all the services currently mandated as part of the public health funding package.

Councils will want to be convinced interventions are genuinely effective while elected members will have a key role to play in deciding the priorities in their areas.

When it comes to re-commissioning services authorities will be looking to providers for creative solutions, says Dr Pearson.

“We might be looking for providers to come up with expanded models or something more integrated across the age range, more closely aligned to the needs of users than traditional NHS models,” she says.

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