By Colin Thunhurst

Health visitors play a vital part in promoting health in the community, but their numbers have been falling. Recent failures in child protection have put them back in the spotlight with the recognition that they could make a difference. The author argues that this focus on their value to society gives the opportunity to explore the leadership role they could play across the boundaries of the different professions.

The role of the health visitor has been placed firmly back on the public agenda. The House of Commons Select Committee on Health Inequalities which reported on 26 February observed that it was “odd” that numbers of health visitors were currently falling. Lord Laming, in his progress report on The Protection of Children in England, published on 12 March 2009 and produced in the wake of the Baby P case, spoke of the “challenges” to be addressed in the Health Visiting Service. Immediately on receipt of Lord Laming’s Report, the Health Secretary Alan Johnson announced that he had asked the Chief Nursing Officer to lead a ‘Programme of Action on Health Visiting’. This is a welcome renewal of interest in what is universally recognised as a demoralised and declining service.

Confused role of health visitors

Lord Laming talked of the need to tackle the confusion “about the role of health visitors who provide a universal service and yet often are called upon to support families with complex needs”. This is certainly necessary, but it is also important to recognise and address the more fundamental tension that exists in the role of health visitors between reducing health inequalities and protecting children at risk. The extent of the current public focus on the latter creates the danger that the forthcoming review will be unduly drawn towards the more immediate role to the neglect of the longer-term and ultimately longer-impacting public health opportunities provided by the unique position of the health visitor.

Despite the publication of the Acheson Report at the turn of New Labour in 1998 and the increased focus on reducing health inequalities, standards of health and well-being across the country are as disparate as ever. With a visible presence within the community and access to many hard to reach groups, health visitors are well placed to bridge the gap between communities and the health service. Their presence amongst the community gives health visitors a voice enabling them to talk to people about their health needs, issues of well-being and general public health messages.

However, the current pressures on the health visiting service and demands on the individual health visitor do not give practitioners time to address wider community issues and start to tackle the problems associated with health inequalities. Too often health visitors find themselves on the back foot of a situation; a process of damage limitation when it comes to child protection. Whilst each individual is working hard to ensure that those at risk, or already in a dangerous situation, are taken care of there is little time to work with the community to improve the social issues which lie behind such cases of child protection.

As long as we have a ‘downstream’ culture in public health and social services we will continue to see cases such as Victoria Climbie and Baby P. Public health professionals need to establish a balance between implementing interventions to prevent health inequalities whilst not neglecting those that slip through the net.

Leadership role of health visitors

One of the main failings identified in Lord Laming’s recent report on child services was a lack of communication and joined up working between different professions in the children’s workforce. Inter-professional working is vital if we are to ease the pressure of responsibility on individuals and make each service more efficient. In studying the role of health visitors recent reports have concluded that there is a golden opportunity here to develop the health visitor in a leadership role; leading a team of professionals from across the spectrum of the children’s workforce. This idea of the health visiting services becoming fully integrated with preventative and protective services for children and families was recommended in the Facing the Future report produced by the Department of Health in 2007 and should provide the starting point for the forthcoming review.

By developing a team of multi-disciplinary professionals working together the barriers usually faced when trying to communicate or work across professions will be addressed. With the health visitor as the central point of contact it will ensure that the relevant mix of skills and experience is involved in any particular situation, that referrals are followed up and that all information is available to all professionals within the team. In this ideal everyone will be aware of the situation, no information will be lost and a more informed decision can be made. The hope is then that a situation where even after over 60 meetings with various professionals a child is killed at the hands of their parents never happens again.

In a leadership role health visitors will be able to look at the preventative side of child protection; working with families and communities to ensure that people are educated about health and well-being and that social issues such as alcoholism and domestic abuse are addressed. As part of our research we have spoken with a number of health visitors and their co-workers to gain their own perspective of their current roles and the potential to develop into the wider remit of public health. The majority of respondents welcomed the idea of a more managerial role, with a responsibility to lead a multi-disciplinary team. However, they also expressed concern at a lack of skills and training to introduce this effectively.

Developing the leadership role

Therefore one of the first steps in developing this new leadership role in public health must be in developing the education and training framework for health visitors and trainees. An overarching and integrative structure has already been provided by the Public Health Skills and Careers Framework. Working with a variety of different professions, possibly under guidance from different authorities will require a generalised but experienced skill set. Health Authorities, PCTs and Universities need to develop training around core management and leadership skills to equip health visitors with the general knowledge to lead a team of professionals, as well as developing their specialist knowledge in community and family health. We must develop training to ensure that both the preventative and reactive elements of the health visitor’s role are developed equally.

This is a classic public health dilemma; how to address wider social issues and health inequalities whilst also helping those that are already vulnerable. We can no longer ignore this dilemma and expect our front-line professionals to shoulder huge amounts of individual responsibility without giving them a chance to work with the community and address major social issues from the outset. Only when we can achieve this balance will the social and health services be able to protect children and young people effectively in a sustainable and manageable system.

On 6 November 2008 the Prime Minister announced that the Secretary of State for Health had asked Professor Sir Michael Marmot to Chair an independent review to propose the most effective strategies for reducing health inequalities in England from 2010. Health visiting should appear prominently in this strategy as the members of the NHS workforce with their roots most firmly embedded in the community. It is to be hoped that their contribution will be spelt out there in a way that synergizes with the review of the Chief Nursing Officer rather than creating a greater tension between their public health and their child protection responsibilities.

Colin Thunhurst is an honorary research fellow and former head of the Public Health Applied Research Group at Coventry University.