Health Visitors (England)
(5 years, 1 month ago)
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Tim Loughton (East Worthing and Shoreham) (Con)
I beg to move,
That this House has considered the reduction in the number of health visitors in England.
I am grateful to the hon. Members who have come to speak on this important subject. I declare an interest as the chair of the all-party parliamentary group for conception to age two—the first 1,001 days. I also chair the board of trustees of the Parent-Infant Foundation, which runs attachment facilities and lobbies for better early intervention around the country.
I will start with some slightly alarming statistics. The cost of perinatal mental ill health in this country has been worked out at £8.1 billion per annum, according to the Maternal Mental Health Alliance, with up to 20% of women experiencing some form of mental health problem during pregnancy or the first 12 months after birth. The cost of child neglect in this country has been estimated at some £15 billion, with 50% of all maltreatment-related deaths and serious injuries occurring to infants and babies under the age of one. We currently spend in excess of £23 billion getting it wrong in those early years, particularly for mums and new babies. That is equivalent to something like half the defence budget.
There are 122,000 babies under the age of one living with a parent who has some form of mental health problem. Amazingly—this statistic came out time and again during conversations on the Domestic Abuse Bill—a third of domestic violence begins during pregnancy, and suicide is one of the leading causes of death for women during pregnancy or in the year after giving birth. About 40% of children in the United Kingdom have an insecure attachment to a parent or carer at the age of 12 months, according to Professor Peter Fonagy and others. Alarmingly, there is a 99% correlation between a teenager experiencing some form of mental illness or depression at the age of 15 or 16 and his or her mother having had some form of perinatal mental ill health during pregnancy. It is that close a correlation, making it that much more important that we make sure that the mums bearing those children, and also fathers, are as happy, settled and healthy as possible in those early stages, from conception to age two.
Luciana Berger (Liverpool, Wavertree) (LD)
The hon. Gentleman set out the costs incurred in trying to prevent such travesties. Does he agree that the figures he refers to are actually conservative estimates? I believe that he was at the launch, quite a number of years ago, of the Maternal Mental Health Alliance, which arrived at the figure of more than £8 billion. Is it not the case that, although the economic costs are significant, it is the social and moral reasons that have brought Members from both sides of the House here for this important debate?
Tim Loughton
If the hon. Lady is patient, I will come on to the social impacts. I think the MMHA report came out in 2014 or 2015, so obviously things will have moved on, although the birth rate has slightly fallen in that time as well. These are substantial financial figures, but as she says, most important are the social impacts and the impact on the child.
On the physical impacts, our childhood obesity rates are among the worst in Europe, while breastfeeding rates in the United Kingdom are among the lowest in the world. We have rising emergency department attendances by children under the age of five, and infant mortality reductions have recently stalled. Just last week, we had the worrying figures about the dwindling vaccination rates in England in particular, with only 86.4% of children having received a full dose of the MMR vaccine. We have effectively lost our immune status, because the World Health Organisation vaccination target to protect a population from a disease is 95%.
The Children’s Commissioner estimates that, in total, 2.3 million children live with risk because of a vulnerable family background, but that, within that group, more than a third are effectively invisible and not known to services and therefore do not get any support. We are talking about an expensive and widespread problem.
Stephen Lloyd (Eastbourne) (Ind)
I pay tribute to the remarkable work of health visitors in my constituency. Does the hon. Gentleman agree that cutting the health visitor service by 30% over the last few years has clearly made it even harder for the profession and for the families and mums that they take care of?
Tim Loughton
Again, I ask the hon. Gentleman to be patient, because I will come on to all that. I realise that he wants to put on the record his tribute to health visitors in Eastbourne, as do I—as someone who was born in Eastbourne and had wonderful health visitors, I am sure, albeit 57 years ago now.
The one thing that all these problems, and a lot more problems I have not mentioned, have in common is that they come under the remit of the health visitor, to some extent or other. The health visiting service provides an important safety net for infants and young children—as well as mums and dads—who are at particularly high risk of having their needs missed, as they are not visible in the same way as children who are accessing an early years setting or a school, for example.
John Howell
I am very pleased to briefly interrupt him my hon. Friend. I pay tribute to the health visitors in my constituency. Is it not an important role of theirs to ensure that health inequalities are drummed out of the system?
Tim Loughton
That is a serious point; my hon. Friend is absolutely right. Health inequalities are still a big problem in this country, and those professionals on the ground, not least health visitors, are the first to come face to face with them and have the practical means, in many cases, to do something about them.
Tim Loughton
I am happy to take interventions, but it will mean that hon. Members will have to make shorter speeches, as I am sure Mr Bone will point out.
Karen Lee
The Royal College of Nursing’s briefing for the debate says that the number of health visitors with caseloads of more than 500 children rose from 12% to 21% between 2015 and 2017, so it will have risen even more in the two years that have elapsed since. The caseload is really worrying, in terms of people being missed.
Tim Loughton
The hon. Lady pre-empts a point I was going to make on page 5 of my notes, so I will take that bit out.
Unlike some other public service professionals, health visitors are non-stigmatising and usually welcomed over the threshold into homes, enabling them to give early advice and support to prevent later problems, encourage healthier choices, detect problems early and, in some cases, act as an early warning safeguarding alarm. Often when social workers are the ones to knock on the door, it may be too late, and that professional has a completely different sort of relationship with the family.
Jonathan Reynolds (Stalybridge and Hyde) (Lab/Co-op)
I am grateful to the hon. Gentleman for securing this timely debate. What he just said is so important. The mandatory health visitor contacts in my constituency are not taking place as they should. When constituents complain or I complain, we are essentially told that they are profiled based on risk, which is clearly not how a mandatory set of contacts should work. I worry that we sometimes make assumptions about socioeconomic status or other factors, whereas the kind of problems we are talking about can manifest themselves in any family. If we are serious about having a mandatory system, should it not be that, rather than discretionary? If it is about capacity, let us talk about that.
Tim Loughton
Again, the hon. Gentleman makes a good point, which was on page 5 of my notes. This issue affects everybody across society, often better-off, more affluent families who might be better at hiding it or less inclined to come forward to seek help. The charity that I chair has units in Liverpool, Newcastle, London and so on, and we see that middle-class parents who have serious attachment dysfunction problems with their children are less likely to come forward. Those, ironically, may be harder-to-reach people. Health visitors are the early warning system and are able to signpost some of those people to services. They can also point out, “I think you have a problem,” and it will be taken on trust.
I appreciate the good points that have been made, but I will make some progress. The cost of failing to intervene early is enormous—financially and, more importantly, socially. The impact of not intervening early can disadvantage a child through early years, school years, adolescence and often into adulthood. In some cases, it can be life-defining.
One of the great achievements of the coalition Government was to pledge a massive increase in health visitors. In opposition, the then shadow Health Minister, Andrew Lansley, championed the recruitment of no fewer than 4,300 new health visitors, based on the successful model of the Dutch Kraamzorg system—I was involved in research into that—where post-natal care is provided to a new mother and her baby an initial eight to 10 days immediately after birth.
Four years ago, the Government’s health visitor implementation plan and the “Call to action” scheme were the pride of the nation. The policy was built on sound evidence that the health visiting profession had the power to drive health improvements and provide a universal service designed to give every child that best possible start in life, as we all want to see. Impressively, for a Government target, it was achieved—just about—in the lifetime of the 2010 to 2015 Parliament.
Depressingly, since then, the numbers have started to drop dramatically. In June 2015, there were 10,042 full- time equivalent health visitors in England. A year later, that had fallen to 9,491 and the latest figures show a 31% drop from the peak. According to the Institute of Health Visiting,
“one in four health visitors do not have enough time to provide postnatal mental health assessment to families at six to eight weeks, as recommended by the government.”
In response to a survey that the institute put out,
“three quarters of respondents said they are unable to carry out government recommended maternal mental health checks three to four months after birth.”
That is a crucial stage at which to pick up mental health problems with the parents, which may already be impacting or will impact on the infant. It is not only about looking after the baby, but the family unit and particularly the prime carer.
To a large extent, the reason for that has been the transfer of responsibility for health visitors from the health service to local government, as part of its enhanced public health responsibilities. I am not challenging the wisdom of doing that, but it has come at the time of the greatest squeeze on local government spending recently. The architecture of the delivery of health and wellbeing services for babies and young children, I think, has been fragmented in a disorienting manner between local councils, Clinical Commissioning groups and NHS England, with insufficiently qualified scrutiny of how it works. There is an issue around the quality of informed local authority oversight over many of these public health roles.
Steve Brine (Winchester) (Ind)
I congratulate my hon. Friend on securing this debate. He has been consistently right in this area. My research ahead of this debate presented a worrying picture from GPs in Winchester, who report a distant relationship with health visitors. That is not their fault; it is because health visitors are so thinly spread. Does he agree that as well as providing more health visitors, it would be smart to address where they sit in the system and, maybe, to co-locate teams around the emerging primary care networks?
Tim Loughton
First, I pay tribute to the real acknowledgment of the importance of this area by my hon. Friend when he was public health Minister. He was always prepared to take our sometimes annoying approaches to prioritising the issue. He may be right. I am not too concerned with processes and structures; I am concerned with getting the professional face to face with the parent and baby. We need to be smarter about where we can make that engagement happen and ensure it is not through lack of workforce that we are unable to do it.
Tim Loughton
If my hon. Friend wants to intervene again, he may, but it will eat into his own speech time.
Steve Brine
The issue is important because the primary care networks and the GPs who rightly run them are responsible for the outcomes of the patients they manage within those lists. If they had ownership of those health visitors, because they were commissioned within that structure, they would have every incentive to close the distant relationship that I mentioned.
Tim Loughton
My hon. Friend may well be right. One of my constituents is a health visitor. According to her, the current status of health is not serving families well, based, as it is, on universally delivered process outcomes, which risk, to use a phrase she quoted to me, “ticking the box but missing the point”. That plays to the point my hon. Friend is making.
To illustrate the most successful ways of dealing with vulnerable families, I will use children’s centres as an example, although I will not get into a whole argument about them. The most successful ones that I have seen are those where hot-desking occurs between a district nurse, a health visitor, a social worker, a school nurse and others, who are all signposting. The health visitor may get over the threshold and say, “I am a bit worried that there is a mental health problem there. When I go back and see the community mental health nurse at the children’s centre, I might suggest she has a word.” That is the way it must happen. These are interlinking problems and it is not just down to one professional to treat them.
On the local authority, public health budgets have seen a significant reduction from 2015. The recent 1% increase for 2021 is welcome, but there is a long distance to go to replace some of the past reductions. Some areas have suffered disproportionately. I want to flag Suffolk, where, I gather, the council has been considering plans to slash the health visiting workforce by 25% to save £1 million. I think that is a false economy and short-sighted.
The decline in the number of health visitors since 2015 has been due to qualified nurses retiring or moving to other roles within the health service and too few trainees entering the profession. Alongside workforce cuts by local authority commissioners, the health visiting profession is also facing recruitment and retention problems, falling staff morale and poor progression opportunities. Health visitors have also raised safeguarding concerns as their caseloads increase to meet increasing need and cover shortages.
In a 2017 survey by the Institute of Health Visiting, health visitors reported that children are put at risk due to cuts in the workforce and growing caseloads, finding that 21% of health visitors are working with caseloads of over 500 children, as the hon. Member for Lincoln (Karen Lee) pointed out.
Jeremy Lefroy (Stafford) (Con)
When health visitors visited me in my constituency surgery in Penkridge, their frustration was that, although they love their job and want to do it properly, they cannot do it to the best of their professional satisfaction, because of the caseloads and because there were too few of them. Health visitors want to serve my constituents—the mothers, families and children—but they cannot, for those reasons. I had huge respect for their professional attitude, but it showed their real sorrow that they could not do the job as well as they want to.
Tim Loughton
My hon. Friend is absolutely right. I have met many health visitors. They are a fantastic resource and do huge amounts of good work well beyond their remit. They are frustrated by some of the processes and financial considerations that are stopping them from doing their job to the best of their ability with sufficient support.
Tim Loughton
This is the last intervention I will take, and I will finish shortly.
Dr Drew
One of the greatest frustrations is when families do not let the health visitors in, which is a growing trend. They come back time after time and they find there is nobody there or, if the people are there, they will not let them in. Does he agree that that is a very worrying development?
Tim Loughton
Earlier, I raised the contrast with social workers where there is a safeguarding issue. It is a completely different dynamic and relationship. There is a reluctance to let the social worker over the threshold. That is less the case with health visitors, because they are seen to be there to help. But there is a reluctance from some people, perhaps due to ignorance as to what the health visitor is there to do from people who think, “I know it all; I don’t need you,” or due to people who may fear that their vulnerability will result in their child being taken into care. That is why that friendly face is so important. The health visitor is on their side to help them in being a new parent, in a way that other professionals cannot be.
According to the state of health visiting survey by the Institute of Health Visiting, one in four health visitors did not have enough time to provide the post-natal mental health assessments to families at six to eight weeks, as recommended by the Government; the hon. Member for Stalybridge and Hyde (Jonathan Reynolds) mentioned that. These PMH checks are a key part of the Government’s maternal mental health pathway. Previous research involving clinical trials with 4,000 mothers found that those who received health visitor support were 40% less likely to develop post-natal depression after six months.
There are five mandated reviews under the healthy child programme that health visitors undertake. While those are spread across the first 1,001 days, they are concentrated in the first 12 months. Health visitors are concerned that the number of reviews is insufficient and leaves too large a gap between contact with families. Not enough scheduled reviews are happening, and we probably need more reviews intensively at those early stages.
There was also a lot of concern about steps being taken to help recruitment. I tabled a question earlier this week, which the Minister kindly answered. I asked
“the Secretary of State for Health and Social Care, what steps he is taking to reverse the fall in the number of health visitors.”
She replied in a written answer, saying that
“Since 2015, local authorities have been responsible for the commissioning of services for zero to five-year-olds and as such, they determine the required numbers of health visitors based upon local needs.”
We understand that. She continued:
“A Specialist Community and Public Health Nurse apprenticeship (Level 7) is currently in development. This will offer an alternative route directly into the health visiting profession.”
I am afraid that that answer raised some alarm among people at the Institute of Health Visiting, and the response to it that I got back was to point out that
“The apprenticeship route is not an alternative route directly into health visiting. Applicants still need to be nurses or midwives and the course presents a number of risks: it is longer, the end point assessment delays qualification unnecessarily…it does not deliver a national strategy for the profession. HVs”—
that is, health visitors—
“who are not employed by the NHS do not have the same opportunities to those covered by the NHS People Plan—this includes NHS funding for CPD”—
that is, continuous professional development—
“leadership development, pay rises, safer staffing and national action to address recruitment/retention difficulties.”
It also pointed out:
“Local Authorities determine the level of HVs dependent on local need, however there is no measure of quality of service or guidance on how far the service can ‘flex’ to meet those needs.”
In addition, the apprenticeship is still not ready to be rolled out; it takes longer than current training; and it is more costly and therefore less attractive to employers and/or recruits.
An urgent workforce plan is needed to tackle dwindling health visitor numbers. I have spoken to representatives of the Local Government Association. They are very concerned about this situation; as representatives of local government, they want to get their public health role right. The LGA said that
“it had offered to work with the Department of Health and Social Care, the NHS and Health Education England to help deliver a plan that would see the ‘right number’ of training places commissioned. It would also develop new policies to ensure health visiting remained an ‘attractive and valued’ profession.”
I hope that the Minister is receptive to that offer; I am sure she is.
What needs to be done? Again, we need to value the role of the health visiting profession. I am sure that all of us in this Chamber and beyond would want to do that, but we have to will not only the inclination but the means as well.
A publication by the Institute of Health Visiting, “Health Visiting in England: A Vision for the Future”, makes 18 sensible and practical recommendations, and they all involve some investment. I will touch very quickly on a few. The institute wants to see
“urgent and ring-fenced public health investment…A review of 0-5 public health funding…to cover the cost of delivery of the Healthy Child Programme in full in all Local Authorities in England.”
All local authorities in England will need that funding. It goes on to say:
“As we await the refreshed Healthy Child Programme, as an interim measure, the proposed metric should be a floor of 12,000”—
that is, 12,000 full-time equivalents—
“to restore the workforce to the target figure calculated for the Health Visiting Implementation Plan, 2011-2015…New National Standards for health visiting are needed to support consistency within the profession. The title ‘health visitor’ and its role should be protected and restored to statute. A review of health visiting training with a risk assessment of the impact of the removal of Health Education England funding of training and replacement by the use of the Apprenticeship Levy.”
Frankly, those are sensible measures. I very much hope that the Minister will look at them positively; I am sure she will. It would be a false economy not to do these things. They need to be part of a bigger shift in Government policy—the policy of any Government; I may be pushing at an open door—towards an earlier, more intensive, preventive intervention approach, from conception to the age of two especially. Health visitors are absolutely at the centre of that.
Several hon. Members rose—
Mr Peter Bone (in the Chair)
Order. It might be helpful to right hon. and hon. Members to let them know that the wind-ups must start at 5.15 pm, and that there are four Members trying to catch my eye. I hope Members can bear that in mind.
Liz McInnes (Heywood and Middleton) (Lab)
It is a pleasure to serve under your chairmanship, Mr Bone, and I am grateful to the hon. Member for East Worthing and Shoreham (Tim Loughton) for securing this important and timely debate.
Before I was elected to this place, I was a lay representative who chaired Unite the union’s national health sector committee. As a result, I had a great deal of involvement in the work done by our health visitors and community practitioners under the umbrella of the Community Practitioners and Health Visitors Association, which operates under the auspices of Unite the union.
I gave up that role in 2014 when I was elected to serve the constituents of Heywood and Middleton. However, I recall that at that time there was great deal of disquiet and unrest about health visitor services, which, as a result of the Health and Social Care Act 2012, were being transferred from NHS commissioning to be commissioned by local authorities. It seems, from what the hon. Gentleman has said and from readily available figures, that the worries that existed at that time have come to pass, as the number of children’s health visitors fell by 31% between 2015 and 2019.
The Local Government Association says that the number of health visitors who are retiring or taking other NHS jobs, combined with too few trainees entering the profession, has led to the workforce being stretched to its limits, at a time when the number of vulnerable children and families is rising.
With cuts to public health budgets, councils are struggling to afford the number of health visitors needed to cope with the workload. Figures from the Office for National Statistics show that the number of under-fives in the borough of Rochdale, in which my constituency is situated, is just over 15,000. With just 52 health visitors in the borough, that gives an average caseload of 290 children per health visitor, when the recommended maximum—as recommended by both the CPHVA and the Institute of Health Visiting— is 250.
With health visitors being so overworked, they may, through no fault of their own, fail to spot child abuse, domestic violence and post-natal depression, and they may also have too little time to help mothers to bond with their babies. A survey conducted by the Institute for Health Visiting showed that health visitors themselves are voicing fears about child tragedy, as a result of increasing case loads and high levels of stress.
With year-on-year cuts to our public health grant, it is difficult to see where the funding will come from to provide and improve this vital service. In the borough of Rochdale, the public health grant is now £3 million lower than it was in 2016-17, having decreased from £19.7 million then to £16.7 million in 2018-19. For this financial year—2019-20—the budget has been cut yet again, to £16.3 million, giving cumulative cuts over the past four years in the borough of Rochdale of more than £8 million. Nationally, councils’ public health budgets have reduced by £531 million between 2015-16 and 2019-20.
I welcome the fact that in the NHS long-term plan the Government pledge to look again at commissioning arrangements, not only for health visitors but for school nursing and sexual health—areas of health provision that are also suffering with increasing caseloads and staff shortages. It is my hope that the responsibility for commissioning will revert to the NHS, and that it will be adequately funded and resourced. I will be very interested to hear the Minister’s comments on that.
Before I conclude, I will just mention some good news about the CPHVA. It has just appointed two high-profile vice-presidents: Professor Gina Higginbottom, who was the first black, Asian or minority ethnic nurse to hold a professorial role at a Russell Group university; and Sara Rowbotham, who is a friend and colleague of mine. Sara worked for Rochdale’s crisis intervention team from 2004 to 2014, and she helped to expose the Rochdale grooming gang scandal. She is also currently the deputy leader of Rochdale Council.
These appointments are welcome at a time when health visiting and school nursing are facing this crisis of falling numbers. Professor Higginbottom has declared her commitment to reducing health inequalities in the role, while Sara has pledged to fight for members’ voices to be heard. I hope that the Minister might find the time to meet these two inspiring women. I am sure that she will find such a meeting productive and helpful in preparing a much-needed clear plan to improve health visiting numbers and the quality of care provided for children and families.
Luciana Berger (Liverpool, Wavertree) (LD)
It is a pleasure to serve under your chairmanship this afternoon, Mr Bone. I congratulate the hon. Member for East Worthing and Shoreham (Tim Loughton) on securing this important debate and on his work with the all-party parliamentary group for conception to age two—the first 1,001 days.
I will start by paying tribute to the Institute of Health Visiting and, most importantly, to the army of health visitors themselves. I know what an important job they do from my own experience as a mum to a two-and-a-half-year-old and a seven-month-old. In particular, I put on record my thanks to Gill and Katie, who have helped me and my family. Health visitors do a brilliant job against a backdrop of falling numbers, growing caseloads and, in some cases, unconscionable pressures. In the wake of the cuts to public health, it is now clear that we have seen a steady diminution in health visitors across England.
As we have heard, since October 2015, the number of health visitors in England has reduced by a quarter from just over 10,000 to just under 8,000, which piles extra pressure on existing health visitors. Nearly a third of health visitors have case loads of more than 500, which is twice the safe level set by the Institute of Health Visiting. Unfortunately, that can only have a detrimental impact on the quality of care. At best, it risks health visitors being less helpful. At worst, it is counterproductive to their aims and goals.
Looking at a number of indicators, we see that there is mounting evidence that things are getting more challenging. The reductions in infant mortality have stalled. We have already heard about issues around breastfeeding, which is a subject that is particularly close to my heart. We now have some of the worst breastfeeding levels in Europe, and I say that as an MP in Liverpool, where so much work has gone on via our Babies and Mums Breastfeeding Information and Support—or BAMBIS—service to support and assist mums in their own homes. We have seen a great increase in the proportion of women breastfeeding in Liverpool, but levels countrywide are still far lower than they should be. We are facing an obesity crisis. Immunisation rates are falling. We have missed the target for measles and the UK has lost its measles-free status. We are living through a mental health crisis, and I reflect on the fact that the period of a woman’s life where she is 30 to 40 times more likely to experience a period of psychosis is the year after birth. That is the moment in her life where extra additional support is needed.
We see a particular challenge with adverse outcomes not being distributed evenly, which speaks to health inequalities. That issue falls far down the agenda and gets much less attention than it deserves, but we are seeing a widening of inequalities across the country. Poor health goes hand in hand with someone’s postcode, income, social status and what their parent or parents do for a living. The impact of inequality is keenly felt in too many areas, including in Liverpool and other disadvantaged neighbourhoods. Nearly 70% of health visitors have reported having to access emergency food aid and go to food banks on behalf of the families they are supporting. The Institute of Health Visiting stated in its report that those inequalities resulted in poorer physical and mental development, poorer academic achievement and poorer employment prospects at every stage of a child’s life.
We are talking about the most fundamental of issues: how can we ensure that every child born in this country has the best life outcomes and best life chances? Health visitors play such an important part in those outcomes and provide such a vital intervention in supporting new parents. The list of what they do goes on and on, and we have heard much about that already. They also play an important part in preventing ill health, rather than trying to cure it later. Health visitors play a critical role beyond health, whether that is supporting troubled families, improving early language development and learning at home, particularly where a child might have special educational needs, or improving parental confidence and knowledge to avoid unnecessary trips to our health service.
Health visitors should form part of a truly integrated system of health, care and wellbeing that is tailored to the parent and child, with the right interventions, advice and support at the right time. I reflect on that as a member of the Health and Social Care Select Committee on. We did a report called “First 1000 days of life”, in which the first priority was for every child to receive the five mandatory visits. In fact, we said that that number should be increased to six, with a visit at three or three and a half years old to ensure that every child is ready for school. We perhaps do not like to talk about that issue, but we are seeing increasing concern about it from teachers across the country.
I am conscious that my time is coming to an end, so I want to reflect on that recommendation from the Health and Social Care Committee. Health visitors play such an important role. They support families where others do not have the opportunity to do so. They enter people’s homes and they are trusted. When I think about all the health professionals I connected with as a new parent, it was my health visitor whom I relied on. We need to ensure that we are not creating the conditions for a public health crisis for future generations, and I hope that in the Minister’s response we will get some glimmers of hope that we will see an increase in the number of health visitors, not a further decrease.
Karen Lee (Lincoln) (Lab)
It is a pleasure to serve under your chairmanship, Mr Bone. I congratulate the hon. Member for East Worthing and Shoreham (Tim Loughton) on securing this vital debate. The role of the health visitor is important to our local communities. The health visiting service provides the vital support that young children and their families need to ensure that every child has the best start in life. Health visitors address cross-departmental priorities for children and give a voice to young children living with adversity, who can in some cases be invisible to other services. The health visiting service provides an important safety net for infants and young children who are at particularly high risk of having their needs missed, as they are not visible in the same way as children who are accessing an early years setting or are at school.
Early intervention is vital for children and their families and an effective health visitor service is a proven way to improve health outcomes and reduce inequalities. However, in January 2019, the Royal College of Paediatrics and Child Health raised serious concerns about widening child health inequalities, highlighting that:
“Universal early years services continue to bear the brunt of cuts to public health services”.
In Lincoln, 28% of children live in poverty. Health visitors are desperately needed to ensure that those children receive the support they deserve. In 2015, the commissioning of health visitors was transferred from the NHS to local government—a bad move in my view—and that has resulted in a negative impact on the working conditions of local health visitors and the capacity of the service delivered to my constituents, as the funding is not ring-fenced. I am deeply worried by the steps that Lincolnshire County Council has taken to divide the health visitor role, and I was proud to support the health visitor strike against the proposed changes.
The changes will divide the health visitor role into two different job descriptions, which will create a flawed career progression scheme that restricts health visitor career progression. All health visitors undertake the same training, and upon qualification they are all expected to carry out every facet of their role on a daily basis. It is my understanding that there is no rationale to explain why one health visitor would be demoted to a junior job description while another continued at the same level. It is a fact that fully qualified top band 6s are leaving or have left—many with years of experience—due to a reduction in their status and an enforced three-year pay freeze. We are losing an important skilled workforce who are invaluable to our community. As a qualified nurse, I have to say that nurses and healthcare professionals do not go on strike without a really good reason.
Analysis undertaken by Unite shows that those held back from progression due to the changes will lose a substantial sum annually in comparison with the NHS pay structure. I am concerned that the reforms are not being undertaken in the best interests of the health visitor service, but rather as a mechanism to deskill the service in order to reduce pay. Financial efficiency must come second to the wellbeing of our local communities. It risks the long-term social benefits created by investing in our children’s future at a crucial early stage. Will the Minister make representations to Lincolnshire County Council—please do not push it to one side and say it is a local government issue—to prevent the downgrading of the health visitor role? It is important in my constituency of Lincoln, and I hope I am being heard. It is important that Lincolnshire County Council recognises health visitors’ professionalism and importance to our community and rewards them accordingly.
Rachael Maskell (York Central) (Lab/Co-op)
It is a pleasure to serve under your chairmanship, Mr Bone. I thank the hon. Member for East Worthing and Shoreham (Tim Loughton) for introducing this important debate. The Labour Government recognised the decline in the number of health visitors and therefore put in train a health visitor implementation plan. As head of health at Unite—I refer Members to my declaration in the Register of Members’ Financial Interests—I was delighted to see that plan come to fruition during my time there. The ambition to raise the number of health visitors by 4,200 was a steep challenge, but a necessary one. We have heard the reasons why. Health visitors are the backbone of early intervention by health services. They are the pioneers of public health, and are instrumental in addressing health inequality. At a time when there are real challenges on children’s health, it is so important that a workforce is there to deliver that service.
Unfortunately, as we have heard, the numbers have fallen by 31% to date, from a peak of 12,292. That is having a serious impact not only on young people and their opportunities but on staff. We know from the work that the Community Practitioners and Health Visitors Association has carried out that 85.3% of health visitors are experiencing stress. They have case loads that are unsafe. It is therefore vital that the Minister put a statutory caseload figure on the books. It is important that health visitors work to criteria under which they can cover their caseloads. In York, we have only 29 health visitors to cover our city, which has a population of nearly 10,000 children. That clearly is not safe at all.
The health visitor implementation plan was good, though very rushed. Often mentoring was being stretched from a one-to-one relationship, which is the norm, to one-to-six. That is what I heard from some health visitors in training. No sustainability was put into the plan after its implementation. Therefore, with an ageing workforce, we saw rapid decline and people moving elsewhere in the health service—partly because they were placed in local authorities that, under the austerity measures, decided to cut back not only on opportunities for training and development but on pay.
Such cutbacks had a significant impact, and downgrading was part of it. For people who went to work in outsourced services, for which we obviously cannot get hold of information about true numbers through freedom of information requests, we know that conditions were even worse, and that people have left the service after their training period. That is a massive loss to our service as a whole.
I will rapidly move on to what needs to be introduced—a new, and properly resourced, health visitor information plan. There was a promise in the report on young people by the right hon. Member for South Northamptonshire (Andrea Leadsom) that the comprehensive spending review would resource the future programme, but of course we have not had the comprehensive spending review. It is therefore urgent that the Government put money on the table to deliver that.
We also need to ensure that we bring services back into health that have been outsourced, so that there is proper monitoring of the service and it is seen as a statutory service to be delivered. I am very interested in the ideas that have been proposed in today’s debate that it either be moved back into the NHS or into a proper partnership between health and local government. The reality is that the right relationships need to be built for health visitors to deliver the programme.
Finally, we need to ensure that the right stakeholders are brought around the table. It has been brought to my attention that some consultation has taken place on how we should move forward on such issues as the number of mandated contacts and so on, but not all the stakeholders are there. I urge the Minister to meet the CPHVA, which is the lead organisation representing health visitors, and to ensure that included in that cohort are people working in the profession who can really reflect what it is like on the frontline today.
Julie Cooper (Burnley) (Lab)
It is a pleasure to serve with you in the Chair, Mr Bone. I thank the hon. Member for East Worthing and Shoreham (Tim Loughton) for bringing this important subject before us, and for the sterling work that he does chairing the all-party parliamentary group for conception to age two—the first 1,001 days.
We have had some really interesting speeches, and I thank all Members who have spoken for some very convincing contributions that have outlined very clearly the massive contribution that health visitors make to communities and to individual families, covering all sorts of services—from basics such as the transition to parenthood, particularly helping new parents, to support with breastfeeding and weaning, and encouraging the full take-up of immunisations. It has been pointed out that we have a very poor record on that. Health visitors also support the mental health of parents who might be feeling vulnerable in their new role; advise on a host of minor ailments from which children might suffer; ensure readiness for school; check that developmental changes are happening at the appropriate stage; and help to pick up early any special needs and problems.
The hon. Member for East Worthing and Shoreham talked about the importance of safeguarding and the cost—not just the cost to the family, but the financial cost of services when it does not happen. Health visitors, as registered nurses with additional midwifery, community and public expertise, play a tremendous role. I do not think that there is any disagreement in the Chamber about the contribution that they make. Praise for them among health professionals is widespread. The president of the Royal College of Paediatrics and Child Health has said:
“Health visitors act as a frontline defence against multiple child health problems”.
The Children’s Commissioner for England said:
“Health visitors are an essential part of the country's support structure for young children and their parents”.
My daughter Anna became a new parent six months ago today. Ahead of the debate, I asked her what she thought of her health visitor. She said:
“We loved our HV. We didn’t have consistent midwifery care—a different midwife every week before and after Nora was born—but we had one HV who first visited me before Nora was born and told me she would be my health visitor throughout the early stages of me becoming a mum. We found her especially helpful when Nora started struggling”
with feeding. Anna also said of her health visitor that
“we’d been discharged by the midwife and didn’t want to bother the GP. She was just a phone call away or would pop to see us.”
I am grateful to the hon. Member for Liverpool, Wavertree (Luciana Berger) for what she said about the benefit she had from health visitors. There is no disagreement about their value, and I put on the record my thanks to health visitors across the country for the sterling work that they do in times of considerable difficulty and challenge. They are very much a British phenomenon. We are the envy of the world, having health visitors—and with good reason. We all know that there is nothing more important than giving children the best possible start in life.
Bearing all that in mind, it is distressing to hear that the number of health visitors is falling so drastically. We are going backwards and it is extremely worrying. The Minister may point to the fact that David Cameron increased the number of health visitors, but that is old news, and the picture now is very different. In 2015, there were 10,300 health visitors; by 2017, that number had fallen to 8,244. The reality is that every month the numbers fall. None of that is really surprising considering that, in late 2015, public health and the commissioning of health visitors became the responsibility of local authorities. That transfer of responsibility was accompanied by a budget reduction of 6.2% and the requirement to cut year on year until 2020. Funding for health visitors is not ring-fenced, so is it any wonder that cash strapped authorities are commissioning fewer and fewer?
I raised my concerns about this last year with the former Health Minister, the hon. Member for Thurrock (Jackie Doyle-Price). She said:
“health visitors are probably the most important army in the war against health inequalities. They provide an intervention that is very family-based and not intimidating…There has been a decline…which we really must address if we are to get the earliest possible intervention and the best health outcomes for children.”—[Official Report, 23 July 2019; Vol. 663, c. 1204.]
I totally agree. That was said last year, and the Government have failed to act and the numbers have continued to fall.
The numbers of children have not fallen, though, and it is therefore important to recognise the increased workload of the remaining health visitors. My hon. Friends the Members for Heywood and Middleton (Liz McInnes), for York Central (Rachael Maskell) and for Lincoln (Karen Lee) all raised the falling numbers, and pointed to the fact that the Institute of Health Visiting current caseload identification exceeds safe levels. The recommended maximum caseload for health visitors is 250. The Care Quality Commission reports that the average is 500 and, in the London Borough of Hounslow, the average number—not the highest—is 829 per health visitor. That is obviously affecting their ability to deliver a quality service, and it is now true that the proportion of six-to-eight-week reviews completed for newborn children ranges from 90% in some areas to only 10% in others. It seems that vital workforce planning is a thing of the past, and our children and communities are paying the price.
In the widest sense, that approach is so short-sighted. No health professional is better placed than a health visitor to support parents and children in those vital early years. The early intervention of a well-qualified, accessible health professional can be the difference between children thriving and not. For every child who does not thrive, there is a cost, not just to the family but to wider society. There is a wealth of evidence to demonstrate the high impact that health visitors have in key areas.
Mr Peter Bone (in the Chair)
Order. I am sorry to interrupt the shadow Minister, but there is a guideline of five minutes for shadow Ministers in these debates, with 10 minutes for the Minister. We are cutting into her time, so I hope the shadow Minister has finished her speech.
Julie Cooper
Today, the Minister has heard an appreciation of the contribution of health visitors. We look to her to address the question of future provision, and outline how she is going to turn around the decline in numbers.
The Parliamentary Under-Secretary of State for Health and Social Care (Jo Churchill)
It is a pleasure to serve under your chairmanship, Mr Bone. I congratulate my hon. Friend the Member for East Worthing and Shoreham (Tim Loughton) on securing this important debate.
I also congratulate Members on the degree of consensus that there has been about how important health visitors are to each and every family they touch. I may not be able to answer Members’ contributions directly, but I will ensure that if there are further points to make after this debate, I will write to Members in due course. I pay tribute to my hon. Friend’s leadership and support on the issue of children and young people, and particularly his efforts to focus on those first 1,001 days, which can impact on social, economic and physical outcomes throughout life. I strongly agree about the importance of early years intervention, and that strengthening support at the very start can stop problems escalating and help the broader family. As both my hon. Friend and the hon. Member for Liverpool, Wavertree (Luciana Berger) pointed out, we can stop these problems before they start, or we can certainly intervene.
My hon. Friend made strong arguments for the value of health visitors and their ability to cross every threshold, which cannot be overestimated. Good health is one of our country’s greatest assets, and we cannot take it for granted; just as we save for retirement, we should be investing in our health throughout life, from the cradle to the grave. Starting in childhood—actually, even before a child is born—we can help to ensure that our children enter the world, and that they are raised, healthy and happy.
Most babies get a fantastic start in life, benefiting from the support of loving parents and dedicated health professionals. However, we know that some lives can be easier than others, often because of circumstances over which those babies have no control and the conditions in which they are brought up. Children who live in more deprived areas are more likely to be exposed to avoidable risks and have poorer outcomes by the time they start school. As the hon. Member for Liverpool, Wavertree pointed out, some of those things have impacts further down the line: at the weekend, a teacher said to me that if a child has poor linguistic skills, that will affect their ability to learn to read because of phonics and so on. It is right, therefore, for support to have a clear focus on reducing inequalities and targeting investment to meet higher needs.
The Government remain absolutely committed to working with partners to identify how to support growth in the community workforce, including through district nurses, general practice nursing, GPs, health visitors and school nursing—the team that my hon. Friend the Member for East Worthing and Shoreham described so well. We are taking significant actions to boost the workforce, including training more nurses, offering new routes into the professions, enhancing reward and pay packages to make nursing more attractive and improve retention, and encouraging those who have left nursing to return. I know that there is still post-qualification, but I do not pretend that there are no challenges; many Members have articulated the challenges that exist, particularly issues such as CPD, which we are aware of and are working on.
We know that the electronic staff records show a reduction in the number of health visitors employed by NHS organisations. However, we also know that this is not a complete picture of the health visitor workforce, who may be employed in social enterprises, private sector organisations or local government. I want to work with partners such as the Local Government Association and the Institute of Health Visiting to establish a much clearer picture, which is what the IHV asked for in its “Health Visiting in England: A Vision for the Future” report—I think it was recommendations 12 and 13. That will help to move the debate forward.
I am pleased that Health Education England is also leading on the development of a specialist community public health nursing standard. That standard will cover several roles, including those of health visitor, school nurse, occupational health nurse and family health nurse, and I am keen for that development to progress swiftly. Currently, as my hon. Friend mentioned, a specialist level 7 community and public health nurse apprenticeship is in development. That apprenticeship will offer an alternative route directly into the health visiting profession, on top of existing pathways that enable people to qualify as health visitors. We must make the best use of these highly skilled and valued members of the profession and of the broader healthcare family, and we must ensure that they can optimise the good they can do when they intervene in children’s lives.
Local authorities remain well placed to commission health visiting and early years support, but they should do so in partnership with all those around them.
Mr Jonathan Lord (Woking) (Con)
Like many other Members, I have been contacted by some terrific health visitors, in my case from Woking. They do a wonderful job, but against a very difficult financial backdrop. As the Minister looks to resource this area in the future, can we make sure that there is fair funding across the country, including to our counties?
Jo Churchill
I thank my hon. Friend for his intervention, which links to the fact that fragmentation also remains a challenge throughout the system, running counter to the aim of whole family support that my hon. Friend the Member for East Worthing and Shoreham mentioned. I believe strongly that there is scope to improve collaboration between councils and NHS bodies in order to improve delivery, particularly on important issues such as breastfeeding, immunisation and the like. The digital child health programme is one area in which we are helping to overcome barriers, securing national backing so that information is shared properly between key professionals. That is particularly important for strengthening the links between primary care and health visitors. However, there are further areas in which we can work together better to support those with higher needs, and I intend to reflect on the points made during this afternoon’s debate and work further on the recommendations of the “Vision for the Future” report.
The commitment to grow the public health grant as part of the local government settlement underlines the Government’s commitment to protecting and improving the health of the population. Local leaders remain well placed to make decisions for their communities; there is a disparity across the piece, and we need to better understand the data. Local decisions should be based on robust assessments of local needs, supported by workforce plans.
Research also suggests that there are short and long-term educational and socio-emotional benefits from early childhood education and care. That is why we have prioritised investment in early education; the 15 hours of free early education for disadvantaged two-year-olds is welcome. However, those benefits start earlier—with a person’s interaction with their health visitor when they are 28 weeks pregnant, or even before that, in personal, social and health education lessons in schools. In those lessons, we talk about healthy relationships and equip our young people with advice on issues such as substance abuse and parenting.
In the prevention Green Paper, we announced our commitment to modernise the Healthy Child Programme to reflect the latest evidence about how health visitors are part of a wider integrated workforce, providing support. Doing so provides an important opportunity to work with partners, and I will take my hon. Friend the Member for East Worthing and Shoreham up on his offer, made in his recent letter, to bring with him academics and other interested parties—I note that there are interested parties across this Chamber—to talk about how we can best move this forward. I want to ensure that support is both universal in reach and capable of a personalised response, focusing support where the additional needs suggest we should put it.
I understand the continued focus on five mandated contacts, which provide a vital opportunity for contact with families, and national data shows that coverage has improved. However, I take on board the points that have been made; I do not want to reduce contact to those five moments, and there have been some interesting conversations about other points of contact. I have heard some within the health visiting profession say that they are being pushed to tick the box but miss the point, and I have spoken to my local health visitor lead about that issue. Health visitors are highly qualified professionals who have an important leadership role, and I wish to reinvigorate that role. Through working closely with commissioners and other professionals, particularly midwives, health visitors are critical to a child’s journey.
If we are serious about supporting early intervention, that means starting with relationships. Becoming a parent is an important time in anyone’s life, but it does not come with a manual; we all need help, and professionals have an opportunity to give evidence-based advice and support. Our vision for prevention encompasses the whole of life. We are now reviewing the prevention Green Paper, including the response to it by my hon. Friend the Member for East Worthing and Shoreham. We will ask ourselves what more can be done, and we will work with local authorities and NHS bodies to address that question.
To give every child the best possible start in life and the opportunity to fulfil their potential, we need to fundamentally change the way we operate. I want to ensure that systems are in place to help infants as they develop, move to school and grow into adulthood; to overcome fragmented service provision; and to make the best of what exists, while using the evidence to maintain a resolute focus on additional needs. I look forward to working with my hon. Friend, and I am optimistic that we can make the change.
Mr Peter Bone (in the Chair)
I apologise to right hon. and hon. Members, but time has beaten us, so I am afraid that the sitting stands adjourned.