PHE Benefits Realisation Report

National Health Visitor Programme –
Benefits Realisation
26 April 2017, Version Final
National Health Visitor Programme – Benefits Realisation Report
About Public Health England

Public Health England exists to protect and improve the nation’s health and wellbeing, and
reduce health inequalities. We do this through world-class science, knowledge and intelligence,
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Prepared by: Dr Helen Duncan with support from Coleen Milligan, Kate Thurland, Zac
Gleisner, Jane Scattergood and Wendy Nicholson.
For queries relating to this document, please contact:

Helen.Duncan@phe.gov.uk
© Crown copyright 2016

You may re-use this information (excluding logos) free of charge in any format or medium, under
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Published August 2017

PHE publications gateway number: 2017238
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Contents
Executive summary ............................................................................................................... 4

Introduction............................................................................................................................ 7
Methodology ........................................................................................................................ 10
Results and discussion ........................................................................................................ 17
Conclusions ......................................................................................................................... 50
Appendix 1: Members of PHE’s Best Start in Life Board ...................................................... 53
Appendix 2: Analytical methodology and statistical tests ..................................................... 55
Appendix 3: Stakeholder survey: questions and intended audience .................................... 66
Appendix 4: Early years profiles - trends in outcomes ......................................................... 70
Appendix 5: Trends in inequalities ....................................................................................... 76
Appendix 6: Case study examples ....................................................................................... 92
Appendix 7: The voices of health visiting service users ..................................................... 109
Appendix 8: Stakeholder special interest groups ............................................................... 121
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Executive summary
Purpose of the report
 This is a retrospective evaluation of the benefits of the National Health Visitor

Programme, which ran from initial announcement in 2010 to programme closure in
2015 following the transfer of commissioning to local authorities.
 The benefits delivered are assessed against the immediate deliverables and
ultimate objectives of the programme by using the measures and feedback loops
which were established during lifetime of the programme.
 The evaluation is directly linked to the time-limited programme and the associated
benefits realisation approach. It explicitly excludes consideration of the levers
utilised to safeguard post-programme sustainability (such as mandation of services
and review of mandation), future changes to local public health funding and
changes to local commissioning arrangements.
Background
 In February 2011, the Department of health published the ‘Health Visitor

Implementation Plan 2011 – 2015 – A call to Action’, which marked the start of a
four year transformation programme, the National Health Visitor Programme, NHVP.
 The enduring components of this programme are increases in the capacity and
capability of the workforce and the redesign of services to maximise benefits from
this increased capacity. This included workforce expansion (4,200 extra health
visitors), professional development and mobilisation of the workforce, improved
commissioning, including metrics and service transformation.
 The programme was delivered in 4 key phases: foundation (2010); initial
implementation (2011-2013); system-wide implementation, following the
establishment of NHS England (2013-2015); and sustainable future (2014 onwards),
which included preparation for and delivery of the transfer of commissioning from
NHS England to local authorities on 1 October 2015, when the programme closed.
 During the programme the health visitor 4 5 6 model was introduced which covers 4
levels of service, 5 universal health reviews and 6 high impact areas.
 This report details an evaluation of the overall aims of the programme; to improve
the health of pregnant women and children by improving access to and experience
of services, improving outcomes and contributing to the reduction of inequalities.
Methodology
 The evaluation was overseen by PHE’s Best Start Programme Board, co-chaired by
PHE’s Chief Nursing Officer and a local authority chief executive, with representatives
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from local government, NHS England, Health Education England, Department of Health
and other government departments.
 Routine data from a range of sources, which was embedded into the system as part of
the programme, was utilised as a main source of information. This includes data on
health visitor numbers, service delivery metrics for the 5 universal visits and outcome
indicators from PHE’s early year’s profiles, many of which are published as official
statistics. Further statistical tests were applied to determine how these had changed
over time and to determine the extent to which outcomes were influenced by the social
determinants of health.
 Stakeholders were surveyed to determine their views on the benefits delivered in the 6
high impact areas of service and this quantitative information was supplemented by
information from health visiting in practice, written up as case studies and feedback
from users collected via mainstream services and existing user forums.
Key findings
 Health visitor numbers increased by approximately 4,000 during the lifetime of the
programme. This is confirmed by official statistics published via the programme
infrastructure. Since the closure of the programme it has not been possible to generate
a complete picture of health visitor numbers in the workforce as the data collection was
labour intensive and the resources required were no longer available.
 Access to services improved for all aspects of the universal service. Numbers of
antenatal contacts doubling in the three years between 2013 and 2016. Plus recent
data on new birth visits indicates they now reach almost 98% of the eligible population,
equating to approximately 640,000 new babies visited per annum. However there is
some variation in service coverage from one local area to another.
 During the lifetime of the programme there were statistically significant improvements
in outcomes for teenage pregnancy, smoking in pregnancy, low birthweight at term,
infant mortality, excess weight at 4-5 years, hospital admissions for injuries under 5
years and coverage of MMR immunisation (2 doses) under 5 years. At the same time
rates of A&E attendance and emergency hospital admission for the under 5 age group
increased but this is similar to the trends seen for other age groups and is generally
considered to be a consequence of insufficient access to primary care. Rates of
breastfeeding at 6-8 weeks, measured using annual statistics, fell during the
programme but applying statistical tests to more recent quarterly data indicates that
these are now starting to improve once more.
 There is evidence to suggest that inequalities in some outcomes reduced during the
lifetime of the programme. This is the case for teenage pregnancy, infant mortality, and
breastfeeding at 6-8 weeks, A&E attendances, emergency hospital admissions and
hospital admissions for injury in the under 5s and also school readiness measured by a
good level of development at the end of reception. In addition, for some outcomes
inequalities were significantly reduced at the end of the programme compared to where
they would have been if the pre-programme trends had continued. This is the case for
teenage pregnancy, A&E attendances, emergency hospital admissions and hospital
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admissions for injury in the under 5s. Notably although inequalities in excess weight at
4-5 years increased during the programme they did so at a slower rate than was
observed in the years leading up to the programme.
 Feedback from parents demonstrated that they valued the service, the support
available, the opportunity to build relationships with professionals and the facility to
access community based peer support groups. They also said they needed to know
more about the service offer and the expertise available to them so that they could
make best use of the opportunity.
Conclusions
 A sustainable benefits realisation approach has been delivered by embedding

the metrics and processes of stakeholder engagement required for tracking
benefits into the system. They have become business as usual and were used to
inform this study.
 The immediate deliverables of the programme including an increase in
workforce numbers, a re-energised workforce and transformed services which
are now reaching the vast majority of the eligible population, have been
demonstrated.
 Stakeholders also identify with the enhanced focus on the high impact areas of
health visiting, recognise the importance of these in delivering improved
outcomes and strongly believe that this will save money in the longer term.
 Evaluation of the underlying aims of the programme revealed statistically significant
improvements in a high proportion of the target health outcomes and some measurable
reductions in inequalities, many of which were ahead of where they might have
otherwise been. Whilst these outcomes are all influenced by a wide range of
background factors and policy initiatives, which mean improvements cannot be directly
attributed to the national health visitor programme, they are underpinned by compelling
real life examples of health visitors in action and feedback from parents which
demonstrate how it is possible for these benefits to accumulate one family at a time to
deliver population level impact.
 It is notable that the benefits realised were delivered during a period of significant
change from an economic and social point of view. Factors such as economic downturn,
prolonged austerity, and revisions to means tested benefits; increased ethnic diversity
and increased immigration of adults of childbearing age generate a challenging
environment for both citizens and services. In this context it is possible that the parallel
investment in health visiting helped to offset some of these risks and in doing so
contributed to the delivery of improved outcomes for mothers, children and their families.
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Introduction
In October 2010, Anne Milton, the Minister for Public Health, set out the Coalition Government’s
vision for the future of health visiting and reinforced the commitment to increase the numbers of
health visitors in the workforce by 4,200 by 2015 and to introduce a new model of service.
In February 2011, the Department of Health published the ‘Health Visitor Implementation Plan
2011-2015 – A Call to Action’ which set out the commitment in more detail. This included securing
a health visiting service which is universal, energised and sustainable. This marked the start of a
four year transformation programme, the National Health Visitor Programme, NHVP, with a
purpose to ‘secure an extra 4,200 health visitors and transform the health visiting service across
England by 2015’. The detail of the programme changed over time but the four enduring
components were:-
 4,200 extra health visitors - a workforce expansion (refocussed training, recruitment and
retention)
 Professional and service transformation - professional development, improved
commissioning of services and improved metrics
 Transformed health visitor service (redesign and new capacity) – new models of delivery,
improved access and improved experience and
 Transfer of commissioning for children’s public health 0-5 years to local authorities
The National Health Visitor Programme ran from 2011 to 2015 with some early mobilisation and
planning work taking place before this. The programme officially closed on 1 October 2015 when
the responsibility for commissioning these services was transferred from NHS England to local
authorities. This change programme was encompassed into 4 key phases:-
 Foundation (2010) – policy commitments, service vision, stakeholder engagement

 Initial implementation (2011 – 2013) – Call to Action, professional development and
mobilisation, workforce planning and trajectories, early implementer sites
 System-wide implementation (2013 – 2015) – core specifications, metrics for performance
management, workforce training and development, NHS England leading commissioning
 Sustainable future (2014 onwards) – focus on high impact areas, NHS England and local
authority shared specifications, professional fellowships and champions, preparation for
transfer to local authorities
The initial work programme included three main themes, as follows
Growing the workforce through new and innovative approaches to training; promoting return to
practice; promoting retention;
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Professional mobilisation to engage and re-energise the profession; promoting learning and
good practice, including in relation to building the capacity of communities to support pregnant
women, new mothers and their children;
Aligning delivery systems, ensuring that robust commissioning, measurement and incentives are
in place to drive progress.
The transformation of the service centred on professional leadership and mobilisation, increasing
capability and professional pride and the implementation of the health visitor 4, 5, 6 model with 4
levels of service, 5 universal health reviews and 6 high impact areas. These are described in more
detail as follows:-
The 4 levels of service – what all families can expect from their local health visitor service.
Community: health visitors have a broad knowledge of the health needs of the community and the
resources available, such as Children’s Centres and self-help groups, work to develop these and
make sure families know about them.
Universal (the 5 key visits): health visitor teams make sure every new mother and child have
access to a health visitor, receive development checks and receive good information about healthy
start issues such as parenting and immunisation.
Universal Plus: families can access timely, expert advice from a health visitor when they need it
on specific issues such as postnatal depression, weaning or sleepless children.
Universal Partnership Plus: health visitors provide ongoing support, playing a key role in bringing
together the relevant local services, to help families with continuing complex needs, for example
where a child has a long term condition, where there are adverse social factors and where there
are safeguarding concerns.
The 5 universal health reviews – all families are eligible for these services. These 5 key visits are
also mandated (local authorities, as commissioners have a continued responsibility to ensure that
these services are delivered).
 Antenatal
 New baby
 6-8 weeks
 9-12 months
1
 2-2 /2 years
The 6 high impact areas – these are dimensions where health visitors have a significant impact
on health and wellbeing. Supporting materials articulate the contribution of health visitors and
describe areas where health visitors have a significant impact on health and wellbeing outcomes
for children, families and communities.
 Transition to parenthood
 Maternal mental health
 Breastfeeding
 Healthy weight
 Managing minor illness & accident prevention
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 Healthy 2 year olds & school readiness
The 6 high impact areas are where health visitors would be expected, at a population level, to have
a significant impact on measurable improvements in health outcomes and on reducing inequalities
in these outcomes.
The day to day focus of the programme was centred on health visitors as a profession, increasing
the numbers in employment within the service and transforming the way in which they work. The
benefits realisation strategy takes a longer term perspective in that it recognises that the enhanced
service must reach more of the population so that needs can be identified and steps taken to
address those needs; whether that be advice, guidance, signposting, direct intervention or referral
to other services. Ultimately improving the health and wellbeing of pregnant women, children and
their families and reducing the extent to which these outcomes might be influenced by the social
determinants of health (deprivation, social status, education etc.) because all families can receive
the service and all input is based on level of need. In addition the universal nature of the service,
the ability to provide more continuity of contact and greater capacity to address needs is expected
to improve the overall experience of service users.
In summary the overall aim of the programme being to improve the health of pregnant women and
children by
 improving access to services

 improving the experience of children and families
 improving health and wellbeing outcomes and
 contributing to a reduction in health inequalities
This report considers the extent to which these overarching aims have been delivered
largely by considering data and information which was either collected during the
programme or has been embedded into the mainstream system.
The production of this report has been overseen by PHE’s multi-agency Best Start in Life
Programme Board (see Appendix 1 for membership).
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Methodology
Information was collected from a number of different sources in order to form a rounded view of the
current service, how it has changed over time, the extent to which it is delivering on its objectives
and the extent to which the benefits of the National Health Visitor Programme have been delivered.
These included analysis of routine data on health visitor numbers in the workforce, service
delivery, health outcomes and the extent to which these are socially distributed.
The views of key stakeholder groups were also sought regarding the importance they placed on
the activities which contribute to each of the six high impact areas and the extent to which these
contribute to the health and wellbeing of the population. This is supplemented by information from
health visiting in practice, written up as case studies and feedback from service users collected via
engagement with existing local mainstream services and user forums. As much as possible data
from different sources and perspectives was triangulated in order to verify findings and test
assumptions. The detailed analytical methodology is included in Appendix 2.
Workforce: Health visitor numbers in the workforce
The trends in health visitor numbers in the workforce were considered using official data from
different sources. This included the NHS electronic staff register (ESR), which is the master record
of current employment and salary payment within the NHS, and also the official statistics published
during the programme as the health visitor minimum dataset (MDS). Both of these datasets are
published by NHS Digital (previously known as the Health and Social Care Information Centre
(HSCIC). In addition, data from a special collection, the Indicative Health Visitor Collection (IHVC)
published by NHS England as management information in support of the later stages of the
programme, was also considered. The two special collections, the health visitor MDS and the
IHVC were discontinued in September 2015 as the programme closed.
Historic information is available from the NHS electronic staff register (ESR) and this collection
also continues to the present date. This is limited as it only covers current employment within the
NHS. It is supplemented by a quarterly collection on numbers of whole time equivalent health
visitors employed within the private sector; this is also published by NHS Digital. There is currently
no workforce collection in place which covers numbers of health visitors who may be employed
directly by local authorities. This means that since the closure of the programme there is no
complete source of data on the whole health visiting workforce.
Service delivery: health visiting service delivery metrics
Quarterly service delivery metrics were reported by NHS England during the NHVP, these are
available at national level.
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Quarterly service delivery metrics have been reported to PHE by local authorities on a voluntary
basis since October 2015, providing data for April 2015 onwards. These now cover all four
quarters of 2015/16 and the first two quarters of 2016/17. Two quarters pre-transfer of
commissioning responsibility and four quarters post transfer. Four of these metrics relate directly to
the regulations mandating their delivery in that they measure service coverage for the population
against specific time points. These are:
 percentage of New Birth Visits (NBVs) completed within 14 days

 percentage of 6-8 week reviews completed
 percentage of 12-month development reviews completed by the time the child turns 15
months
 percentage of 2-2½ year reviews completed
For each of these metrics it has been possible to apply statistical tests at national level to the PHE
data (see Appendix 2) to determine the trend over time at national level. These are described as
improving, deteriorating, no evidence of trend and insufficient data.
In addition, a composite trend over time has been defined across the four service points balanced
in line with the aspirations of the regulations. The detailed definitions and statistical approach is
available in Appendix 2 with the overall service delivery trends described as follows:
 improving
 stable with some areas of improvement
 stable
 deterioration of one or more mandated elements
 insufficient data
For contacts within the antenatal period it has only been possible to consider the number
of visits and not the population coverage. This is due to technical issues with defining a
robust and reliable denominator for this indicator.
Health outcomes: PHE’s early years’ profiles
All relevant outcomes indicators have been incorporated into mainstream reporting routines across
the system and outcomes which feature in the Public Health Outcomes Framework dominate the
landscape for children’s public health.
PHE provides routine monitoring for a range of health and wellbeing outcomes indicators that
relate to the 0-5 years population in line with the six high impact areas for the universal health
visiting service. These are published on PHE’s Fingertips reporting solution as PHE’s early years’
profiles at national and local levels, as follows:
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High impact area Outcome indicator Status
Transition to parenthood Teenage pregnancy rates Established

and the early weeks
Smoking in pregnancy Established
Low birth weight of term babies Established

Infant mortality Established
Maternal (perinatal) Maternal mental health In

mental health development
Breastfeeding Breastfeeding at 6-8 weeks Established
Healthy weight Excess weight at 4-5 years Established
Managing minor illnesses A&E attendance rates, under 5 Established

& reducing accidents years
Emergency hospital Established
admissions, under 5 years
Hospital admissions for injuries, Established
under 5 years
Health, wellbeing and Tooth decay at 5 years, Established
development average number of decayed
teeth
MMR immunisation coverage Established
(2 doses) at 5 years
Development outcomes at 2- In
21/2 years development
School readiness, good level Established
of development at end of
reception
For each of these established indicators it has been possible to apply statistical tests (see
Appendix 2) to determine the trend over time from the baseline of 2010 or as close to the start of
the programme as possible up to the date for the latest available data. These trends have been
calculated at national level and are each described as improving, deteriorating, stable or too early
to say.
Inequalities in health outcomes
The outcomes indicators listed above are also used to monitor inequalities on an ongoing basis.
These analyses fall into different groupings depending on the granularity of the data available.
The detailed technical methodologies are included in Appendix 2.
 Inequality gap – deprivation
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This is the outcome gap between children living in the most deprived decile (10% most
deprived areas of the country) and the children living in the least deprived decile (10% least
deprived areas of the country). See Appendix 2 for detailed methodology.
 Inequality gap - other

This is the outcome gap between children who can be assigned to a particular subgroup,
for example children eligible for free school meals (a cohort potentially experiencing a
greater level of economic hardship than their peers) and all other children who fall outside
this subgroup.
 Inequality gradient
This describes the extent to which the outcome is distributed according to a social gradient,
in this case by area deprivation. This methodology is described in detail with worked
examples in Appendix 2.
o Where data for the indicator is available at record level each record is allocated to a
decile of deprivation based on the child’s postcode of residence. The gradient of the
slope is then calculated in a way which includes adjustments for the number of
records located within each decile of deprivation, see Appendix 2. This gradient is
known as the Slope Index of Inequality (SII). The steeper the gradient the greater
the social distribution observed in the outcome indicator. On the whole outcomes
are worse for children living in more deprived areas and better for children living in
less deprived areas.
o Where data for the indicator is available only at aggregate level, for example by local
authority, the assigned level of deprivation, which is an average across the
geographic area, is used to rank and place the record with a decile of deprivation.
Many indicators are strongly correlated with deprivation when considered in this
way. The average outcome for each decile is calculated and plotted against the
deprivation deciles and the gradient of the line of best fit gives some measure of the
extent to which deprivation may influence outcomes. It is not as sensitive as the
Slope Index of Inequality as the data is considered in larger blocks and therefore
more homogenised.
In all these cases the inequality gap or inequality gradient is considered at different time points
and the extent to which inequalities existed and were changing over time before the start of the
NHVP (considered to be before 2010 or 2010/11) is compared with the extent of inequalities and
how they changed over time during the implementation of the programme (considered to be 2010
or 2010/11 to 2015 or 2015/16).
Stakeholder views: survey of key stakeholders
The views of a wide range of stakeholders were gathered using an online survey.
In addition to other things this survey covered benefits realisation from the six high impact areas
of service and also a question on the perceived return on investment from these services. The
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questions for the survey were developed and approved by PHE’s Best Start in Life Programme
Board. A copy of the Programme Board membership is included in Appendix 1 and the survey
questions in Appendix 3.
Links to the survey along with a covering letter inviting participation were distributed to the target
audience via their representative bodies or membership organisations as follows:
Stakeholder Individual role Distribution via

group
Local authority Chief executive Society of Local Authority Chief

Executives (SOLACE)
Director of public health Association of Directors of
Public Health (ADPH)
Director of children’s Association of Directors of
services Children’s Services (ADCS)
Health and wellbeing Local Government Association
board chair (LGA)
Portfolio holder for public
health
Lead member for children
and young people
Commissioner
Health services, CCG commissioners NHS England regions – nursing
NHS Service provider leads
Health visitors Health visitor Institute of Health Visiting
(iHV)
Community Practitioners and
Health Visiting Association
(CPHVA)
School and Public Health Nurses
Association (SAPHNA)
Royal College of Nursing (RCN)
The survey ran from 29 June to 31 July 2016. Response volumes were tracked on a weekly basis
and prompts issued to encourage engagement with the process.
Survey responses relating to the six high impact areas and return on investment were analysed
using quantitative approaches. The survey as a whole also included open questions to help elicit a
more detailed understanding and these were analysed on a thematic basis. The details of these
statistical techniques and approaches are included in Appendix 2. In broad terms, the closed
questions tested for differences of opinion between key stakeholder groups on a proportionate to
ensure that the views of each stakeholder group were considered equally. All the survey results are
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shown throughout the report as tables (showing rounded figures for ease of interpretation) and
charts (derived from the unrounded percentages).
Case studies
Case studies were collected from the health visiting service via a number of routes including:-
 Published journal articles, sources such as Community Practitioner
 Published guidance such as ‘Improving outcomes for children and families in the early
years: A key role for health visiting services’ published jointly by the Local Government
Association and the Institute of Health Visiting in January 2007.
 Harvesting presentations and posters from national and local health visiting conferences
and workshops
 Case studies published by the Institute of Health Visiting
 Case studies published by individual organisations in order to share best practice
 Through professional networking
Existing materials were utilised as much as possible, case studies were pulled into a standard
format and mapped to the 4 5 6 service model shown in order to ensure coverage of the
agenda. The case studies were interspersed throughout the analysis in order to be presented
in context. More detail is available in Appendix 6.
Service user experience
More than 500 parents were engaged in facilitated discussions at various locations across
England and representing a wide range of ethnicity and socio-economic status. Conversations
were guided using a structured questionnaire, which was informed by the literature. All the
engagement was structured via existing mechanisms and gatherings (such as child health drop-in,
postnatal illness support groups, domestic abuse survivor groups, aqua-natal, aqua-mummies,
soft play areas, swimming lessons, coffee and chat groups, bumps and babies groups, children’s
centres activity groups). The findings were transcribed and analysed on a thematic basis by the
facilitator. More detail is available in Appendix 7.
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Return on investment
A question on perceived return on investment for these services was posed as part of the
stakeholder survey. The question is detailed in Appendix 3 and the analytical methodology
described in Appendix 2.
During 2016-17 PHE commissioned Optimity Advisors to assess evidence on the effectiveness
and cost-effectiveness for health visitors as delivery agents of the Healthy Child Programme. This
work is based on secondary research and evaluates UK and international evidence covering both
universal and targeted services delivered by health visitors.
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Results and discussion

Health visitor numbers in the workforce
Published statistics on the numbers of health visitors in the workforce are presented in Table 1,
Figure 1a and Figure 1b using the different information sources available.
Table 1: Health Visitor numbers from various sources: Indicative Health Visitor Collection
(IHVC), Health Visitor Minimum Dataset (HVMDS) and electronic staff record (ESR)
Last updated: March 2017
Indicative Health Health Visitor Electronic Independent sector
Visitor Collection Minimum Staff Record health visitors (NHS
(NHS England) Dataset (HSCIC) (NHS Digital) Digital)
Sep-09 8,100
Apr-10 7,918
Apr-11 7,668
Apr-12 7,746
Apr-13 8,110
Apr-14 10,395 10,389 8,948
May-14 10,389 10,382 8,927
Jun-14 10,345 10,350 8,887
Jul-14 10,274 10,298 8,828
Aug-14 10,228 10,265 8,766
Sep-14 11,138 10,800 9,162
Oct-14 11,247 11,102 9,481
Nov-14 11,290 11,239 9,629
Dec-14 11,310 11,268 9,639
Jan-15 11,828 11,643 9,889
Feb-15 11,982 11,838 10,075
Mar-15 12,157 12,077 10,257
Apr-15 11,984 11,929 10,185
May-15 11,878 11,850 10,111
Jun-15 11,807 11,744 10,042
Jul-15 11,713 11,690 9,943
Aug-15 11,637 11,642 9,928
Sep-15 11,955 11,895 10,236 957
Oct-15 n/a n/a 10,309
Nov-15 n/a n/a 10,279
Dec-15 n/a n/a 10,212
Jan-16 n/a n/a 10,213
Feb-16 n/a n/a 10,178
Mar-16 n/a n/a 10,144 924
Apr-16 n/a n/a 9,711
May-16 n/a n/a 9,592
Jun-16 n/a n/a 9,491
Jul-16 n/a n/a 9,385
Aug-16 n/a n/a 9,311
Sep-16 n/a n/a 9,521 1,132
Oct-16 n/a n/a 9,410
Nov-16 n/a n/a 9,376
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Note: The different reporting systems are not directly comparable and careful interpretation of these numbers is
required. In addition, ESR data only relates to whole-time equivalent numbers currently employed within the NHS.
Snapshot counts of health visitors working in the independent sector were taken at September 2015 and March 2016.
More detail is provided in the following commentary.
Figure 1a: Annual health visitor numbers from electronic staff record (ESR)
Last updated: February 2017
10,500
10,000
9,500
9,000
health visitors
8,500
Number of
(FTE)
8,000
7,500
7,000
6,500
6,000
Apr 10 Apr 11 Apr 12 Apr 13 Apr 14 Apr 15 Apr 16
Figure 1b: Published health visitor numbers, monthly, showing gap in reports between
Indicative Health Visitor Collection (IHVC), Health Visitor Minimum Dataset (HVMDS) and
electronic staff record (ESR) with periodic data from the independent sector.
Last updated: March 2017
13,000
12,000
IHVC
ESR figure plus
957 reported as working ESR figure plus ESR figure plus
in independent sector 924 reported as working
11,000 MDS in independent sector
1,132 reported as working
in independent sector
health visitors
10,000
Number of
(FTE)
ESR
9,000
8,000
7,000
6,000
Apr-14 Jun-14 Aug-14 Oct-14 Dec-14 Feb-15 Apr-15 Jun-15 Aug-15 Oct-15 Dec-15 Feb-16 Apr-16 Jun-16 Aug-16 Oct-16
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The number of health visitors in employment increased by approximately 4,000 between 2010 and
2015 as can be seen from Figures 1a and 1b. This was a direct result of the activities of the
NHVP. During the lifetime of the programme, the numbers were tracked via the Health Visitor
Minimum Dataset (MDS) a set of official statistics published by the Health and Social Care
Information Centre (HSCIC). The Health Visitor MDS included data from the NHS electronic staff
record (ESR), which can only report on whole-time equivalent numbers in employment within the
NHS at any point in time, data collated on health visitors employed by social enterprises, private
providers, local authorities and also data on health visitors returning to practice.
Reporting of the health visitor MDS was not particularly timely due to lengthy quality assurance
processes and so an additional special collection, the Indicative Health Visitor Collection (IHVC)
was introduced in April 2014. The IHVC was published as management information but provided a
more real-time indicative view of the workforce. Through the IHVC it was possible to understand
the planned workforce by considering the workforce establishment (including filled posts and any
current vacancies) and also to track the pipeline of new health visitors graduating from and
engaged in training.
Both the health visitor MDS and the IHVC were stood down in September 2015, with the closure
of the NHVP, and when the responsibility for commissioning these services transferred to local
authorities. This also coincided with a consultation and revision of the way in which NHS
workforce statistics were reported, which was implemented from September 2015.
Table 1 and Figure 1b show that during the final year of the health visitor programme there was a
reasonably consistent gap (approximately 1,700) in health visitor numbers reported by the health
visitor MDS and by the NHS ESR. At this time, the gap would be made up of health visitors
employed outside the NHS and those returning to or just starting in practice for whom employment
had not yet been recorded onto ESR.
Since October 2015, it has only been possible to track health visitor numbers using the ESR
supplemented with a periodic collection on health visitors employed within the independent sector.
This has limitations as not all health visitors are employed within the NHS and the ESR data
includes no information on vacancies. Also the data is reported in arrears and the latest data
available is November 2016. In addition, some changes have been made to the way in which ESR
data is reported, which were implemented from September 2015 onwards. They include changes
to how staff are counted, as well as which organisations are included across the NHS. For this
reason, a cautious approach needs to be taken to the interpretation of this data and it is clear that
since the closure of the programme there is no longer a complete set of data on health visitor
numbers within the system.
Figure 1b, using ESR data, shows a stable post-transfer picture for the second half of 2015/16
followed by an overall decrease in the numbers employed by NHS providers between peak values
in October 2015 to a minimum value in August 2016. It is not clear how much if this decrease of
998 may be due to periodic fluctuations (as numbers are affected by annual training and
recruitment cycles) or changes in commissioning approach. There was an increase in numbers
19
employed by the NHS in September 2016 of 210 which is when new trainees are expected to
enter the workforce.
At the peak of the NHVP funded training places commissioned by Health Education England
(HEE) peaked at approximately 1,000 per annum. For the academic year 2015/16 (884/1,042),
some 85% of these places were filled. Back in 2016 it was considered too early to tell if the gap
between the planned and actual education commissions reflected some uncertainty on the part of
professionals, or was simply due to the winding down of the NHVP although it was reported that
organisations were looking at new models of service delivery.
The training places for 2016/17 were published by HEE in December 2016 when funded places
were adjusted to a maintenance level of 817. Latest figures from HEE show that 555/817, some
68% of these places are now expected to be filled. From the ESR data it is clear that not all new
trainees have found or will find employment as health visitors. The under recruitment to training
places reflects current employer demand with reconfigured services across the country simply not
recruiting as may health visitors as they might have done previously.
NHS Digital run a data collection on the numbers of health visitors in employment in non-NHS
organisations such as private sector organisations, community of interest organisations and social
enterprises. The latest figures were 957 in September 2015, 924 in February 2016 and 1,132 in
September 2016. Two providers submitted data to this collection for the first time in September
2016. This data is provided on a voluntary basis by the organisations themselves and it is not
known to what extent it maybe complete, which makes it difficult to draw any firm conclusions. It is
possible that there are some shifting employment patterns, for example it appears that numbers
employed outside the NHS are increasing at the same time as numbers in the NHS are falling.
It is not clear how many may health visitors may have been transferred from an NHS employer to
a non-NHS employer or employed directly by local authorities as service contracts have been
renegotiated and/or services have been brought in house by local authorities. It is also possible
that the recent drops may be due to a cautious approach to recruitment on the part of employers,
given active recommissioning within the sector, deliberating over decisions on whether or not to fill
vacancies. It is not currently possible to generate a complete picture as there is no published data
available on the number of health visitors employed directly by local authorities.
It is not currently possible to monitor the evolution of the public health workforce in general and
consideration should be given to the extent to which a workforce data collection which crosses
different settings and supports future workforce planning, may be required. This will become
increasingly important as the workforce progressively becomes embedded in non-NHS settings.
However, whilst the NHVP focussed on increasing the numbers in the health visitors in workforce
and transforming the service the benefits realisation is more concerned with the improvements in
outputs and outcomes delivered by that transformed service.
Stakeholder feedback indicates that local authorities are now concentrating on integrating
services, introducing more skill-mix to teams and reducing investment in these services. Alongside
this, health visiting roles are being redefined for system leadership, uniquely providing the
20
professional input to more skill-mixed teams. With this in mind the natural conclusion would be that
future services will require the same or fewer numbers of health visitors.
Service delivery: health visiting service delivery metrics
Statistical tests have been applied to all information on service delivery,

inequalities and outcomes. The details of these tests are described in Appendix 2.
All trends and differences described in national service delivery metrics, outcome
indicators and inequalities in these indicators or surveyed opinion by stakeholder
group are significant.
Using service data from NHS England from April 2013 to December 2014 the
trends in service delivery can be considered during the later stages of the NHVP
and more recent data published by PHE covers the transfer of commissioning to
local authorities. This coverage data is presented in Table 2.
Table 2: Summary of trends in health visitor service delivery in England from

2013/14 to 2016/17
Summary of Health Visitor Service Delivery Metrics for England
Overall trends through transfer: Improving

Note: Overall trend is based on trends for indicators C2, C8i, C5 and C6i
First two quarters of 2016/17, data published January 2017. All quarters of 2015/16, data published October 2016.
Data for 2013/14 and 2014/15 published by NHS England.
2013/14 2014/15 2015/16 2016/17

Indicator Quarter 1 Quarter 2 Quarter 3 Quarter 4 Quarter 1 Quarter 2 Quarter 3 Quarter 4 Quarter 1 Quarter 2 Quarter 3 Quarter 4 Quarter 1 Quarter 2 Trend
C1: Number of mothers who received a first
face-to-face antenatal contact with a Health N/A 32,541 32,845 36,353 38,804 45,232 50,162 N/A 60,873 63,620 63,875 66,224 71,737 72,542 Not applicable
Visitor at 28 weeks or above
C2: Percentage of New Birth Visits (NBVs)

N/A 73.6% 74.4% 73.5% 74.7% 79.2% 81.5% N/A 85.6% 86.9% 87.6% 87.8% 87.9% 88.5% Improving
completed within 14 days

N/A 21.6% 19.3% 20.6% 20.2% 16.9% 13.9% N/A 11.8% 10.3% 10.1% 9.5% 9.7% 9.3% Not applicable
completed after 14 days
C8i: Percentage of 6-8 week reviews completed N/A N/A N/A N/A N/A N/A N/A N/A 79.3% 78.8% 80.1% 83.1% 81.1% 81.9% Improving
C8ii: Percentage breastfed at 6-8 weeks 45.7% 45.7% 45.7% 46.2% 44.6% 44.1% 43.7% 42.9% 44.2% 43.1% 43.0% 43.9% 44.7% 44.4% Improving
C4: Percentage of 12 month development

reviews completed by the time the child turned N/A 64.6% 62.5% 63.6% 64.5% 66.9% 68.5% N/A 72.1% 72.6% 72.7% 73.2% 73.8% 75.3% Not applicable
12 months
reviews completed by the time the child turned N/A 64.2% 70.3% 73.4% 76.2% 77.5% 76.4% N/A 79.8% 80.0% 80.8% 82.4% 81.7% 82.5% Improving
15 months
C6i: Percentage of 2-2½ year reviews

N/A 63.4% 67.1% 66.6% 72.6% 68.0% 69.0% N/A 71.2% 73.1% 74.2% 74.6% 75.9% 78.1% Improving
completed
C6ii: Percentage of 2-2½ year reviews

completed using ASQ-3 (Ages and Stages N/A N/A N/A N/A N/A N/A N/A N/A 71.3% 77.8% 86.7% 88.5% 85.5% 88.5% Improving
Questionnaire)
Here it can be seen that there is a sustained increase in the proportion of eligible
children who have had access to the universal visits within the healthy child
programme, both during the implementation of the programme and beyond. In
21
addition the numbers of pregnant women having contact with health visiting
services during the antenatal period more than doubled from 32,541 in quarter 1 of
2013/14 to over 72,542 in quarter 2 of 2016/17.
The trends in service coverage using early data from NHS England and later data
from PHE are shown in Figures 2a, 2b, and 2c for new birth visits, 1 year reviews
and 2-21/2 year reviews.
Figure 2a: Trends in service coverage, new birth visits
C2: Percentage of New Birth Visits (NBVs) completed within 14 days

Recent trend: Improving
100%
90%
80%
Data from 2015/16 Quarter 1
reported by Public Health England
70%
Data up to 2014/15 Quarter 3
reported by NHS England
60%
50%
40%
30%
20%
10%
0%
2013/14 2013/14 2013/14 2013/14 2014/15 2014/15 2014/15 2014/15 2015/16 2015/16 2015/16 2015/16 2016/17 2016/17
Quarter 1 Quarter 2 Quarter 3 Quarter 4 Quarter 1 Quarter 2 Quarter 3 Quarter 4 Quarter 1 Quarter 2 Quarter 3 Quarter 4 Quarter 1 Quarter 2
Figure 2b: Trends in service coverage, 1 year review
C5: Percentage of 12 month development reviews completed by the time the child
turned 15 months
100%
90%
80%
70% Data up to 2014/15 Quarter 3 reported by Public Health England
reported by NHS England
60%
50%
40%
30%
20%
10%
0%
2013/14 2013/14 2013/14 2013/14 2014/15 2014/15 2014/15 2014/15 2015/16 2015/16 2015/16 2015/16 2016/17 2016/17
22
Figure 2c: Trends in service coverage, 2-21/2 year review
C6i: Percentage of 2-2½ year reviews completed

100%
90%
80%
70%
Data up to 2014/15 Quarter 3 reported by Public Health England
60% reported by NHS England
50%
40%
30%
20%
10%
0%
2013/14 2013/14 2013/14 2013/14 2014/15 2014/15 2014/15 2014/15 2015/16 2015/16 2015/16 2015/16 2016/17 2016/17
Looking more closely at recent trends in service delivery and actual levels of
service in the later stages of the NHVP, through transfer of commissioning and
beyond gives the current position of the service and some indication of
sustainability.
National data reported by PHE for quarterly health visitor service delivery metrics
during 2015/16, the year of transition and the first two quarters of 2016/17, is
shown in Table 3 below.
23
Table 3: Summary of trends in health visitor service delivery in England

Summary of Health Visitor Service Delivery Metrics for England
Overall trends through transfer: Improving

First two quarters of 2016/17, data published January 2017. All quarters of 2015/16, data published October 2016.
2015/16 2016/17
Indicator Quarter 1 Quarter 2 Quarter 3 Quarter 4 Quarter 1 Quarter 2 Trend
face-to-face antenatal contact with a Health 60873 63620 63875 66224 71737 72542 Not applicable

85.6% 86.9% 87.6% 87.8% 87.9% 88.5% Improving

11.8% 10.3% 10.1% 9.5% 9.7% 9.3% Not applicable
C8i: Percentage of 6-8 week reviews completed 79.3% 78.8% 80.1% 83.1% 81.1% 81.9% Improving
C8ii: Percentage breastfed at 6-8 weeks 44.2% 43.1% 43.0% 43.9% 44.7% 44.4% Improving

reviews completed by the time the child turned 72.1% 72.6% 72.7% 73.2% 73.8% 75.3% Not applicable
12 months
reviews completed by the time the child turned 79.8% 80.0% 80.8% 82.4% 81.7% 82.5% Improving
15 months

71.2% 73.1% 74.2% 74.6% 75.9% 78.1% Improving
completed

completed using ASQ-3 (Ages and Stages 71.3% 77.8% 86.7% 88.5% 85.5% 88.5% Improving
Questionnaire)
It can be seen that the service is improving on all four of the delivery points, which
can be tracked for population coverage and timeliness. These relate to the
coverage in quarter 2 2016/17 as follows:
 new birth visit – 88.5 %
 the 6-8 week visit – 81.9 %
 the 1-year review – 82.5% and
 the 2-21/2 year review – 78.1%.
Although the mandation of service requires a new birth visit to be

completed within 14 days some are completed later than this, a
percentage which is falling. For quarter 2 2016/17 88.5% of new birth
visits were completed on time and 9.3% were completed late. Together
this gives a total of 97.8% of the eligible population reached by this
service. An impressive level of coverage for a universal service
considering the fact that new parents have a choice regarding whether
or not to take up the service.
Commentary from the stakeholder survey explains that parental engagement is

slightly more difficult at the older ages as mothers have generally returned to work
24
and this tailing off is shown in the coverage statistics.
Taking all the trajectories on balance, it can be stated that the overall service
delivery trend is one of improvement at a national level. In other words, on the
whole, access to services improved throughout the NHVP and this momentum was
sustained from April 2015 through the transition to local authority commissioning in
October 2015 and forward to the end of September 2016, which is the most recent
time point that could be included in this study.
From the more recent PHE data the overall service delivery trend in access to
services have also been calculated at a regional level and the results are shown in
Table 4.
Table 4: Regional trends in health visitor service delivery metrics from April
2015 to September 2016 (inclusive).
Region Overall trend in service delivery

East Midlands Stable
East of England Improving
London Improving
North East Improving
North West Improving
South East Improving
South West Deterioration of one or more mandated elements
West Midlands Deterioration of one or more mandated elements
Yorkshire and the Humber Improving
The deterioration in some aspects of service noted for the West Midlands relates only to
completion of the review at 1 year. In the South West deterioration in service is noted for three
aspects of service, the new birth visit, the 6-8 week review and the 1 year review, whilst coverage
of the 2-21/2 year review is improving.
Some local areas are reporting almost universal levels of coverage for the health
visitor reviews while some local areas are reporting levels which indicate that a very
reduced service is available. The regional average picture on population coverage
for the four aspects of universal service which can be tracked is shown in Table 5
and Figure 5 for Quarter 2 of 2016/17.
25
Figure 5: Population coverage for universal services, regional average in

Q2 2016/17
100%
90%
80%
70%
60%
NBV within 14 days

50%
6-8 week review
12 month review by 15 months
40%
2-2½ year review
30%
20%
10%
0%
North East North Yorkshire East West East of London South East South
West and The Midlands Midlands England West
Humber
Table 5: Population coverage for universal services, regional average in

Q2 2016/17
From Table 5 and Figure 5 it can be seen that for most regions the universal service
is delivered on balance to at least 80% of the eligible population of children and in
some regions to 90% or above. The exception is London where although coverage
of the new birth visit is high at 91.1%, this tails off for the later visits with only 54.1%,
64.0% and 57.4% of children were seen at 6-8 weeks, 1 year and 2-21/2 years
respectively during quarter 2 of 2016/17. Despite data quality issues, reporting
26
problems due to changes in IT systems and difficulties in attracting the desired

number of health visitors to the region through the duration of the health visitor
programme, London has shown improvement on overall population coverage from
April 2015 to September 2016 but clearly started from a weaker baseline than the
rest of the country.
At a local level the variation in service coverage is even greater with a number of
local authorities delivering some elements of the universal service to less than 50%
of the eligible population of children in quarter 2 of 2016/17. These figures are
shown in Table 6.
Table 6: Number of local authorities in service coverage bands, Q2 2016/17

Number of local authorities
less than 50% between 50 and between 60 and between 70 and between 80 and between 90 and
completed 60% completed 70% completed 80% completed 90% completed 100% completed
C2: Percentage of births that receive a
face to face New Birth Visit (NBV) within 14 4 1 1 9 46 85
days by a Health Visitor
C8i: Percentage of infants who received a
6-8 week review by the time they were 8 10 2 9 14 42 59
weeks
C5: Percentage of children who received a
12 month review by the time they turned 15 8 6 8 16 35 70
months
C6i: Percentage of children who received
13 7 6 27 44 45
a 2-2½ year review
Here it can be seen that during quarter 2 2016/17 the service was delivered to less
than 50% of the eligible population by 4 local authorities at the new birth visit, by 10
local authorities at 6-8 weeks, by 8 local authorities at 1 year and by 13 local
authorities at 2-21/2 years.
Notwithstanding the underlying issues with data quality and data availability, it
seems in some cases that whether or not families benefit from this service depends
on where they live in the country. The lower starting point in terms of service
provision at the point of transition may explain this to some extent. The underlying
reasons for this variability in service levels are not clear but the picture is reinforced
by the commentary provided as part of the stakeholder survey where some issues
are raised to do with the sustainability of the service.
Health outcomes: PHE’s early years’ profiles
National data on health outcomes indicators relating to 0-5 years, which is monitored
on an ongoing basis in PHE’s early years’ profiles, is shown in Figure 6 below. The
detailed trends for each indicator are shown graphically in Appendix 4.
These indicators have been monitored since 2010, at the start of the NHVP, and the
most recent annual data relates generally to 2015/16. The data for these indicators
derives from multiple sources. Due to the lag inherent in data flows and the national
production of official statistics, the trends over time observed here are directly
27
related to the period of sustained investment in health visiting.
Where there was sufficient data to both calculate the annual indicators and
successfully analyse the trends over time, it can be seen that during the period of
investment many of these indicators improved. At national level there have been
improvements in teenage pregnancy, smoking in pregnancy, low birth-weight at
term, infant mortality, excess weight, hospital admissions for injury and coverage of
the MMR vaccination. While these improvements cannot be directly attributed to the
health visiting service, which is just one component of a complex and dynamic public
health system, health visitors are well placed to inform and influence the multiple
individual decisions made within families which help to drive these outcomes.
At the same time some deterioration has been observed in annualised rates of
attendance at A&E, emergency hospital admission rates and annualised rates of
breastfeeding at 6-8 weeks. For breastfeeding, this is regrettable given that rates in
England, at an overall value of 43.2% during 2015/16 for breastfeeding at 6-8
weeks, compare unfavourably on an international basis. (See Lancet series on
breastfeeding).
Increases in A&E attendance rates have been seen in all age groups and this is
thought to be predominantly due to structural factors within the NHS such as timely
access to GP services.
It should not be overlooked that breastfeeding rates are influenced by a range of

complex factors such as cultural norms, health services, community based services,
community groups and direct interaction with key professionals such as midwives,
GPs and health visitors. Midwifery services, which are commissioned by CCGs, are
critical to provision of breastfeeding information during the antenatal period and
have direct impact on the initiation of breastfeeding shortly after delivery. However,
breastfeeding is also amenable to influence by the health promotion, nutrition and
weaning advice, guidance and support given by health visitors, and the data at 6-8
weeks is reported via this service.
Statistical tests from more recent quarterly data on breastfeeding at 6-8 weeks for 6
data points collected during 2015/16 and for the first two quarters of 2016/17, see
Table 3, are now showing an improving trend in quarterly breastfeeding rates
boosted by a high point of 44.7% measured between April and June 2016. This
trend will continue to be monitored for the remainder of 2016/17. Annual figures for
2016/17 will be published in October 2017.
Figure 6: Trends in annual outcomes indicators at national level
28
Early Years Profile: England

Latest data as of February 2017
High impact Key performance Current Range (all local Trend since
area indicators performance authorities) 2010
i
22.8 per 1,000 15-17 Best: 8.4
Teenage pregnancy rates Improving
year olds (2014) Worst: 42.4
i
Best: 1.8%
Transition to Smoking in pregnancy 10.6% (2015/16) Improving
Worst: 26.0%
parenthood and the
i
early weeks Best: 1.3%
Low birth weight of term babies 2.8% (2015) Improving
Worst: 4.8%
i
3.9 per 1,000 live Best: 2.0
Infant mortality Improving
births (2013-15) Worst: 7.9
Maternal (perinatal) Not

Maternal mental health Metric in development
mental health applicable
i
Best: 76.5%
Breastfeeding Breastfeeding at 6-8 weeks 43.2% (2015/16) Deteriorating
Worst: 18.0%
i
Best: 14.9%
Healthy weight Excess weight at 4-5 years 22.1% (2015/16) Improving
Worst: 27.4%
h
A&E attendance rates, under 5 587.9 per 1,000 Best: 335.0
Deteriorating
years (2015/16) Worst: 1836.1
Managing minor
h
Emergency hospital admissions, 155.0 per 1,000 Best: 57.3
illnesses & reducing Deteriorating
under 5 years (2015/16) Worst: 307.9 x
accidents
i
Hospital admissions for injuries, 129.6 per 10,000 Best: 56.0
Improving
under 5 years (2015/16) Worst: 254.2
Tooth decay at 5 years, average
0.84 per child Best: 0.37 Too early to
number of decayed, missing and
(2014/15) Worst: 2.46 say
filled teeth
h
MMR immunisation coverage at Best: 98.6%
88.2% (2015/16) Improving
Health, wellbeing and 5 years Worst: 56.5%
development
Development outcomes at 2- 2½ Not
Metric in development
years applicable
School readiness, good level of Best: 78.7% Too early to

69.3% (2015/16)
development at end of reception Worst: 59.7% say **
** Not enough data points to calculate a trend, due to methodological changes in 2012
Key
Increasing, improving h
Decreasing, improving i
Increasing, deteriorating h
Decreasing, deteriorating i
Stable 1
29
There is a marked variation in breastfeeding rates at 6-8 weeks across the country.
During 2015/16, rates for English local authorities varied from 18.1% to 76.5%, and
this is an area for attention from the perspectives of both policy and practice.
National data on the health outcomes which are tracked in PHE’s early year’s
profiles derives from different sources. Some of these are collected nationally at
record level and some are only available at aggregate level, which limits the ways in
which inequalities can be investigated.
Indicators available at aggregate level include teenage pregnancy, smoking in

pregnancy, low birthweight of term babies and breastfeeding at 6-8 weeks. The
impact of area deprivation has been considered by using data at local authority level
to calculate an inequality gradient for each year. This is less sensitive than the
analysis which can be carried out on record level data where the slope index of
inequality is calculated for each year. Record level information is available for
indicators on infant mortality, excess weight at 4-5 years, A&E attendances,
emergency hospital admissions and hospital admissions for injuries.
Survey data on tooth decay at 5 years has been considered by correlating levels of
decay with the deprivation within a local authority area.
The indicator on school readiness comes from the Department for Education and the
inequalities gap considered is published for children who are eligible for free school
meals.
The methodologies utilised for the different indicators are described in Appendix 2.
Whether at record level or aggregate level the outcome for records which fall into the
lowest decile of deprivation can be compared with those which fall into the highest
decile of deprivation. Deprivation inequality gaps and how they appear to be
changing over time are described below. These are considered for time periods
during the NHVP or as close as possible (2010 or 2010/11 to 2015 or 2015/16) and
also the period immediately preceding the programme (before 2010 or 2010/11).
This is so that changes over time and any discontinuities can be examined. The
detailed charts are included in Appendix 5.
 Teenage pregnancy – appears that the outcome gaps between the least and
30
most deprived cohorts are closing over time with a more recent noticeable
acceleration in the improvement for the most deprived cohort.
 Smoking in pregnancy – appears that the outcome gaps between the least
and most deprived cohorts are fluctuating in recent years with no readily
observable trend.
 Low birtheight at term – appears that the outcome gaps between the least
and most deprived cohorts were narrowing before the programme and have
stabilised in recent years.
 Infant mortality - it appears that the outcome gap between the least and most
deprived cohorts is steadily closing over time.
 Breastfeeding at 6-8 weeks - appears that the outcome gaps between the
least and most deprived cohorts maybe narrowing overall but with some
fluctuations from one year to the next.
 Excess weight at 4-5 years - it appears that the outcome gap between the
least and most deprived cohorts is widening over time.
 A&E attendances under 5 years - it appears that the outcome gap between
the least and most deprived cohorts was widening over time before the start
of the programme and then appeared to be reasonably stable throughout the
duration of the programme.
 Emergency hospital admissions under 5 years - it appears that the outcome

gap between the least and most deprived cohorts is closing over time.
 Hospital admissions for injuries under 5 years - it appears that the outcome
gap between the least and most deprived cohorts is closing over time.
 Tooth decay at 5 years – it appears that the correaltion between tooth decay
and deprivation is not changing over time.
 MMR coverage at 5 years – there is no discernable impact of deprivation on

this indicator.
 School readiness – although it appears that levels of school readiness are

improving over time there have been methodological changes, resulting in
31
discontinuities in the trend data, which sometimes make it difficult to compare

one year with the next. However it appears that in recent years there has
been a small year on year reduction in the gap between those eleigible for
free school meals and those not eligible.
Rather than considering the gap in outcomes between those living in the most
deprived and least deprived areas of the country it is also possible to measure the
way in which outcomes gradually deteriorate as area deprivation increases by
calculating the Inequality Gradient or the Slope Index of Inequality when record level
data is available. These social gradients have been calculated for each year
throughout the NHVP and in the time leading up to this change programme. The
individual slope indices and gradients are detailed in Appendix 5 and Table 7 below
summarises how inequalities changed over time during the programme, 2010
(2010/11) to 2015 (2015/16) and compares these with how the inequalities were
changing over time during the preceding years, 2005 (2006/07) to 2010 (2010/11).
By following this approach it has also been possible to quantify the impact which the
NHVP may have had on inequalities by comparing inequalities at the end of the
programme with the projected outcome which would have resulted if the trends in
inequalities observed at the beginning of the programme had continued. Detailed
calculations are included in Appendix 5 and a summary of the results is shown in
Table 7 below.
Table 7: Change in level of inequality for key outcomes during the National
Health Visitor Programme
INDICATOR CHANGE IN LEVEL OF INEQUALITY LEVEL OF AVERAGE

INEQUALITY IN MOST
PRE- PROGRAMME DURING RECENT YEAR COMPARED
PROGRAMME WITH PROJECTION OF PRE-
PROGRAMME TRENDS
Teenage Reduced by 10% Reduced by 37.4% 40% better
pregnancy (2006 – 2010) (2010 – 2014)
Smoking in Not available Increased by 13.1% N/A
pregnancy (2010/11 – 2015/16)
Low birthweight Reduced by 25.3% Increased by 5.0% 60% worse
at term (2005 – 2010) (2010 – 2015)
Infant mortality Reduced by 22.5% Reduced by 15.7% 35% worse
(2006 – 2010) (2010 – 2015)
Breastfeeding at Not available Reduced by 35.8% N/A
6-8 weeks (2010/11 – 2015/16)
Excess weight at Increased by 19.5% Increased by 11.4% 15% better
4-5 years (2007/08 – (2010/11 – 2015/16)
2010/11)
32
A&E attendances Increased by 1.3% Reduced by 6.3% 3% better

under 5 years (2007/08 – (2010/11 – 2015/16)
2010/11)
Emergency Reduced by 9.3% Reduced by 31.0% 20% better
hospital (2006/07 – (2010/11 – 2015/16)
admissions under 2010/11)
5 years
Hospital Reduced by 6.0% Reduced by 31.0% 25% better
admissions for (2006/07 – (2010/11 – 2015/16)
injuries under 5 2010/11)
years
Tooth decay at 5 Unchanged (survey data from 2008, N/A
years 2012/2015)*
MMR coverage at Methodology not applicable – no N/A
5 years distribution by deprivation detected
School readiness, Not available Appears to be N/A
good level of reducing
development at
end of reception
*National Dental Epidemiology Programme for England: Oral Health Survey of five-year-old children 2015
It can be seen from Figure 6 and Table 7 that rates of teenage pregnancy are falling
and also inequalities are reducing at a faster rate than they were before the start of
the programme. Health visitors are in a position to discuss contraception and help to
prevent early second pregnancies. Any second pregnancy during the teenage years
would be included in the overall teenage conception rates but cannot be tracked
separately because of the way in which the data is collected. It is also recognised
that the availability of long acting reversible contraception (LARC) has had an impact
in this area.
Overall rates of smoking in pregnancy, low birth weight for term babies and infant
mortality have improved (see Figure 6) yet inequalities have increased for smoking
in pregnancy and low birthweight at term (see Table 7). In addition although
inequalities for infant mortality reduced during the programme they did so at a
slower rate than was observed before the start of the programme. This is a complex
picture of interrelated factors as smoking in pregnancy is a known risk factor for both
low birthweight and for infant mortality. Other research has shown that young, white
mothers from deprived areas of the country are more likely to smoke during
pregnancy than other cohorts. It is possible that more could be done to target this
group which would require input from midwifery service, health visiting services and
population level prevention campaigns. Case study evidence (Appendix 6, case
study K) suggests health visitors can be successful in smoking cessation although
this maybe later in motherhood rather than during pregnancy.
33
This study has not considered the underlying impact of ethnicity and changes in the
maternal population on inequalities in either low birthweight at term or infant
mortality. However, it is recognised for example that some ethnic groups, such as
Pakistani and Bangladeshi, generally have smaller babies, are concentrated into
more deprived areas of the country, and experience higher rates of infant mortality
due to cultural factors such as cousin marriage. A health visitor can have impact on
birthweight for second children via healthy eating and lifestyle advice, including
smoking cessation and on infant mortality through input on safe sleeping.
Although overall levels of breastfeeding at 6-8 weeks fell during the programme the
inequalities have improved (see Figure 6 and Table 7). This is an area where the
universal service can have a direct impact but it is also dependent upon successful
initiation generally delivered via the midwifery service.
Tracking excess weight at 4-5 years is critical to the government’s childhood obesity
strategy. During the programme the outcomes improved (Figure 6) and although
inequalities were still increasing through this time it was at a much slower rate than
observed before the programme started (Table 7). Health visitor delivered advice
and support to all families on weaning, healthy eating and physical activity is
important to this success.
The significant contribution from universal health visiting services to managing minor
illnesses, home safety and accident prevention is shown in the way that inequalities
reduced during the programme, also at a faster rate than pre-programme, for A&E
attendances and hospital admissions (Table 7). This is an important success as the
hospital system overall is challenged with increasing admission rates and
admissions are disproportionately high for those living in more deprived areas.
Notably hospital admissions for injuries in the under 5’s are falling.
Stakeholder views: Survey of key stakeholders
The stakeholder survey attracted a good response with 3,704 submissions. The
majority of these (3,130 responses) were from health visitors themselves. The
details of three high level stakeholder groups and respondent role types are shown
in Table 8 below.
Table 8: Survey responses received, by respondent role

Role (grouped by type) Number of
responses
Local authority 284
- LA chief executive or elected member 41
34
- Director of public health 79

- Director of children's services 24
- Local authority commissioner 140
Health services, NHS 290
- CCG commissioner 61
- Provider of health visiting services 229
Health visitors 3,130
Total 3,704
A total of 284 responses were from staff based within local authorities ranging from
the chief executive and elected members, directors of public health and of
children’s services and the commissioners themselves. In some cases, individuals
within local authorities responded from their own professional, role-based
perspectives. In other cases, they put forward a corporate, shared position. It is
clear from some responses that some organisations are working in close
collaboration with a common strategic position and shared service contracts.
In the interests of preserving confidentiality and encouraging open responses, the

survey did not seek to identify the local authority from which the respondent came,
just the region. This means that as 284 responses came from 150 local authorities,
good coverage can be assumed, although it is not known whether the views of all
local authorities have been represented. There is, however, a good spread of local
authority based respondents across England, as seen in Table 9 below.
Table 9: Regional distribution of responses to stakeholder survey

Region Number of local authority responses
East Midlands 15
East of England 32
London 49
North East 13
North West 39
South East 49
South West 30
West Midlands 25
Yorkshire and the Humber 31
Good coverage can also be assumed from the health service perspective, with
responses from all regions. There are currently 209 clinical commissioning groups
(CCGs) and approximately 135 providers of health visiting services. A total of 290
responses were received from CCG commissioners and from providers of health
visiting services. Approximately one third of the health visitor workforce responded
to the survey.
35
Importance of the universal health visitor reviews to delivering the

benefits of the Healthy Child Programme 0-5 years
The Healthy Child Programme 0-5 years and the components which are delivered
by the health visiting service are described as six high impact areas, as follows:
 transition to parenthood
 maternal mental health
 breastfeeding
 healthy weight
 managing minor illness and accident prevention and
 healthy two-year-olds and school readiness
These have then been broken down into more detailed task-based areas of activity,
especially for transition to parenthood further exploring the specific focus of:
 healthy lifestyle, including home environment

 contraceptive and sexual health advice
 smoking cessation and
 secure attachment and bonding
Survey respondents were invited to comment on the extent to which they think the
universal health visitor reviews are important to delivering the benefits of the healthy
child programme by answering the following question:
“How important do you think the universal health visitor reviews are to delivering the
benefits of the Healthy Child Programme 0-5 years in the following areas?”
a) Transition to parenthood – supporting the parents, providing advice and
guidance healthy lifestyle and preparing the home for the new baby
b) Transition to parenthood – contraceptive and sexual health advice to support

planned pregnancies or parenthood
c) Transition to parenthood – advice and guidance on smoking cessation in

pregnancy and to reduce harm to baby from second hand smoke (tobacco
control priority)
d) Transition to parenthood – advice and guidance on establishing secure

attachment and bonding, home learning environment
e) Maternal mental health – assessment, brief intervention and signposting to
36
other support services; being mindful of paternal wellbeing and good mental
health as a mechanism for supporting healthy relationships
f) Breastfeeding – advice, education and practical support, including

signposting to other support services in order to initiate and sustain
breastfeeding (childhood obesity priority)
g) Healthy weight – advice and education on nutrition, weaning, healthy eating

(including access to means-tested vouchers for fresh fruit, vegetables and
vitamins) and physical activity (childhood obesity priority)
h) Managing minor illnesses and accident prevention – advice and guidance,

illness escalation approaches, support uptake of childhood immunisations,
home safety environment
i) Healthy two-year-olds and school readiness – safety net on new-born and

infant screening, child development assessment aged 2–21/2 years,
supporting parents to articulate development concerns (special needs) with
access to early help, onward referral to other services (paediatrics, speech
and language etc)
Allowable responses were:
 extremely important
 very important
 somewhat important
 not so important
 not at all important
 don’t know
This question was asked of local authority directors of public health, directors of
children’s services, local authority commissioners, as well as health services staff
and health visitors.
The results for all three stakeholder groups are covered as follows and
accompanied by case studies, as relevant, demonstrating outcomes from the
transformed service for the individual subject areas.
37
Figure 10: Summary of responses to the question: “How important do you

think the universal health visitor reviews are to delivering the benefits of the
Healthy Child Programme 0-5 years in the following areas?”
Local authorities:
Health services, NHS:
Health visitors:
38
Table 10: Summary of responses to the question: “How important do you

think the universal health visitor reviews are to delivering the benefits of the
Healthy Child Programme 0-5 years in the following areas?”
Note: all results are statistically significantly different unless stated otherwise.
* In transition to parenthood – smoking cessation results shown for ‘Health services, NHS’ and
‘Health visitors’ are not statistically significantly different from each other
It can be seen from Figure 10 that all aspects relating to the six high impact areas
are regarded as important to delivering the benefits of the Healthy Child Programme
0-5 years by all stakeholder groups to a greater or lesser extent. Health visitors are
more polarised in their views, more often selecting the ‘extremely important’
category. Health service respondents use the ‘very important’ category more often
than health visitors while the local authority respondents are yet more cautious in
their approach making more use of the ‘very important’ and also the ‘somewhat
important’ category. There are very few respondents who think these services are
‘not so or not at all important’ to the delivery of the benefits.
Overall, maternal mental health and issues of secure attachment and bonding are
rated a slightly more important than other aspects of activity in both the volume and
strength of the response on importance across all three stakeholder groups. This is
not surprising given the high level of national and local emphasis on this aspect of
service following the recommendations of the Mental Health Taskforce and the
Maternity Review and the policy priority to improve perinatal mental health. In
addition, approximately 700 practitioners, the majority of whom are health visitors,
have been trained as Maternal Mental Health champions and more than 10,000
professionals (health visitors and other practitioners) have received cascade
39
training in this subject.
Case Study Maternal Mental Health
‘Time for Me’ Appendix 6, case study A

During a universal visit a health visitor noticed that a new mother had poor eye
contact with her baby and that the home was in a poorly maintained state. After
the health visitor had explained her role in maternal mental health the new mother
disclosed that she had been bullied as a child, had previously self harmed, had
low self-esteem and was now feeling isolated. The health visitor identified low
mood and high anxiety by applying the Edinburgh Postnatal Depression Scale and
the Generalised Anxiety Disorder Assessment. Following this she supported the
new mother into, weekly group sessions designed for those experiencing anxiety
or depression in the antenatal or postnatal periods and also continued to monitor
the situation and provide support on a one to one basis. Following the sessions
the new mother reported improved mood, more energy, and more enthusiasm to
play with her child and was generally more open about her feelings. Since that
time she has since continued to socialise with the other mothers from the support
group, has accepted a funded nursery place for her child and taken up a part time
job.
Case Study Maternal Mental Health
‘Knowing Me, Knowing You’ Appendix 6, case study B

A facilitated support group for mothers with identified mental ill health, developed
in collaboration with MIND and the local Perinatal Mental Health team, who also
supervised the service. Sessions are facilitated by a wellbeing practitioner from
MIND, a nursery nurse and a health visitor and referrals can come from GP’s,
health visitors or the mothers themselves. Input includes information, advice and
support for living with mental health difficulties with a focus on responsive
parenting. Aims to reduce symptoms build confidence and develop social support
structures. Importance of the social network exemplified via establishment of a
follow on group facilitated by the mothers themselves called ‘Knowing Us’.
Stakeholders have made recommendations for putting more capacity into the
system, to focus on maternal mental health, in particular to consider the need for an
additional review at 3-4 months. Breastfeeding, weaning, physical activity and
accident prevention can also be covered by providing more support for parents at 3-
4 months. The extent to which these are thought to be important and the strength of
importance falls in the order: breastfeeding, healthy weight (weaning, nutrition and
physical activity) and accident prevention, although all are well supported.
40
Case Study Managing minor illnesses and

accident prevention
Families in temporary Appendix 6, case study C

accommodation, Choose Well
Campaign
Targeting families and expectant mothers living in temporary accommodation,

which poses risks due to limited space, communal living and lack of familiarity with
layout. Visits to refuges and events co-ordinated with Child Safety Week using
materials based on Choose Well Campaign, which helps families understand how
to identify and access the appropriate level of healthcare when needed. Also
covered home safety teams and equipment, fire safety schemes and home safety
checklists. 75% of participants said they were better informed and had made
positive changes to keep safe and use health services at the right level.
Case Study Managing minor illnesses and

accident prevention
Child Accident Prevention Trust Appendix 6, case study D

resources, training on managing
minor ailments
Professional development was undertaken by assessing the literature, attending
specialist training on minor ailments and preparing a presentation for use with
parents, which was developed around a prevention framework published by the
Child Accident Prevention Trust. Led community based workshops on accident
prevention and the management of minor ailments. Set up a telephone helpline to
help worried parents with advice and signposting to other services. Provided a
shorter input via mother and toddler groups and one to one sessions where
required. Also delivered public health promotion in local shopping centres and
schools. Feedback from parents included increased confidence in managing
childhood illnesses, accident prevention and knowledge of access routes to out of
hour’s services and services for minor ailments. Locally some impact on A&E
attendances was observed potentially influenced by this new service and other
relevant developments.
The importance of the universal health visiting service to establishing meaningful

contact between professionals and families in order to encourage breastfeeding has
been reinforced by submissions from the GP Infant Feeding Network (GPIFN) and
UNICEF (see Appendix 8). Experts from the British Heart Foundation National
Centre for Physical Activity and Health (BHFNC) Early Years Advisory Group have
also written to emphasise the importance of these services to the achievement of
healthy weight covering both breastfeeding and physical activity (see Appendix 8).
41
Case Study Breastfeeding
‘Breastfeeding drop in’’ Appendix 6, case study E

New mother struggling to breastfeed following late diagnosis of a tongue tie
resulting in poor latch, thrush and blocked ducts. Still struggling at 9 weeks with
poor latch and nipple damage. Plus worried about prospect of formula feeding due
to a family history of diary allergy. Attended dedicated drop in sessions for
breastfeeding support which were followed up with home visits and additional
telephone support. By 13 weeks all the issues had been addressed and the baby
was still feeding at 9 months old. The mother reported positive psychological
impact, improved bonding between herself and the baby, who continued to thrive
and a real sense of achievement.
Healthy weight, including diet and physical activity, is one of the six high impact
areas of health visiting and PHE has worked with the profession to produce
additional guidance in this area. The potential impact of the universal health visiting
service on the government’s childhood obesity priority is considered as part of
this study and responses to the stakeholder survey tells us that the health visitor
reviews are seen to be important to achieving a healthy weight by all stakeholder
groups. In this context, activities include advice and education on nutrition, weaning,
healthy eating (including access to means tested vouchers for fresh fruit,
vegetables and vitamins) and physical activity.
Case Study Healthy weight
HENRY, www.henry.org.uk Appendix 6, case study F

Lifestyle/behaviour change
programme focussing on food,
activity and parenting
A boy with autistic spectrum disorder was seen at 2-21/2 years by the universal
service. He had restricted his own diet to biscuits and crisps. In addition his
younger sister, who was 8 months old, was opportunistically assessed, found to
be obese and have delayed development of gross motor skills as a result.
Following a brief intervention on portion size and healthy eating the family were
referred to HENRY, an 8 week programme delivered in the home. This resulted in
a change to the pattern of meals and the family diet. Also specialist nutritional
input for the boy recommended not to make mealtimes stressful and to introduce
vitamin supplementation. The outcomes are that the girl is now a health weight
with the right gross motor development for her age and the boy is eating from all
food groups. The mother reports that mealtimes are much happier and she quotes
that she, “found the HENRY 1 to 1 course really beneficial, it was easy to fit into
family life. Trying anything new is always hard in the beginning but by the end of it
you don’t realise you are doing it, it just became second nature. I would
recommend that anybody give it a try if it is offered to them!”
This is followed in strength by support for healthy two-year-olds and school

42
readiness. This support is consistent across all three stakeholder groups and ties
with stakeholder recommendations for the introduction of a further, specific review
with a focus on school readiness. Again the views of the local authorities are less
categorical than the health visitors or the health services, yet still predominantly on
the positive side.
Case Study Healthy 2 year olds and school

readiness
‘Hello Goodbye’ Appendix 6, case study G
Popular and efficient workshops for parents and children designed to facilitate the
handover from health visiting to school nursing, which are supplemented by the
attendance of doctors and dentists. General issues such as oral health, healthy
eating and physical activity are addressed through interactive play, giving children
an opportunity to socialise. Other issues pertinent to school readiness such as
sleep, potty training and tantrums are also covered to help prepare the children
and their parents for the school setting. Professionals also have an opportunity to
carry out necessary assessments in order to identify any additional needs.
A major component of school readiness is the development of speech, language

and communication skills, which are in turn influenced by secure bonding, mothers
talking to their babies and a rich home communication environment. The
importance of the universal health visiting service in encouraging these activities
and spotting any delays in the development of these skills has been reinforced by
submissions from I CAN, the children’s communication charity and the
Communication Trust (see Appendix 8). Early development of good communication
skills is in turn pivotal for accessing education, securing employment and
maximising social justice, which generally result in a positive contribution to
society.
Case Study Healthy 2 year olds and school

readiness
Speech Language and Appendix 6, case study H
Communication Skills
– ‘Home Talk’
At the 2-21/2 year review health visitors identify children with delays in
development of speech, language or communication skills and refer them to
Home Talk, a specialist home visiting service delivered by qualified speech and
language therapists. These specialists work with the children to improve skills and
also to identify any complex problems which may require more intense support.
Increased referrals to Home Talk have reduced referrals to speech & language
therapists at a later stage, when problems may have become more entrenched.
Health visitors have also become better at identifying needs and signposting to
early help.
43
The aspect of transition to parenthood, which also includes supporting parents,

providing advice and guidance on healthy lifestyle and preparing the home for the
new baby, is rated as high in importance but the extremely important rating is much
more prevalent with health visitors than it is with local authority respondents.
Stakeholders reinforce the importance of an assessment of the home environment
and of understanding the child and providing safeguarding oversight within the
context of the whole family and the home environment.
Case Study Transition to parenthood – secure

attachment and bonding
New-born Behavioural Observation Appendix 6, case study I
Exhausted parents with a constantly feeding baby were concerned by the baby’s
unsettled crying. The mother was anxious and tearful. The health visitor
suggested using the New-born Behavioural Observation system, which the
parents agree to. This allowed parents to see relaxed and responsive handling
and learn how to sooth the baby. The health visitor also had the opportunity to
discuss the benefits of skin to skin contact and explain the bonding process.
Parents began to relax through the session and celebrate the baby’s
achievements. Parent’s later feedback was that they were much happier, could
read cues and settle the baby. The mother was also enjoying breastfeeding.
Within the overall context of the healthy child programme 0-5 years, the universal
health visitor reviews were regarded as less important to delivering benefits from
contraceptive and sexual health advice than from all other aspects of service. It is
not clear why this might be, however, within the system this type of advice would
also be coming from a number of other sources such as midwives, GPs and
specialist family planning or sexual health services. Sexual health services are also
mandated services, with their own dedicated workforce. However, it is clear from
case study evidence that health visitors can have a direct impact in this area.
Case Study Transition to parenthood –

contraception and sexual health
advice
Teenage parents outreach Appendix 6, case study J
A local area established a new service for teenage parents. This included school
based clinics, drop in at supported young parents housing projects and young
parents groups. Young parents were surveyed to identify their view of the health
visiting service and their health needs. As a result gaps were identified in the
service and in health visitor training including updates on contraception and
sexual health and an appreciation of the best way to establish good
communication with teenage parents. Following this positive feedback was
received regarding the specialist input of health visitors.
The contribution of health visiting to providing advice and guidance on smoking

cessation in pregnancy and reducing harm to babies from second hand smoke is
44
considered to be less important than some other aspects of service, although the
overall importance is still rated highly. This relative view may be moderated by the
fact that midwives are much better placed within the system to deliver advice on the
benefits of smoking cessation during pregnancy as they have more contacts during
this time period. Also, if attempts to stop smoking are unsuccessful during
pregnancy, they may be even more challenging after the baby has returned home.
However, health visitors are uniquely placed with their universal access into the
home to provide advice and encouragement for new parents to stop smoking or, at
minimum, providing encouragement to avoid smoking in the presence of the new
baby.
Case Study Transition to parenthood - Smoking

cessation
‘Quit 4 Life’ Appendix 6, case study K
Health visitors identify smokers during pregnancy and hold a focussed discussion
on smoking and the benefits of quitting. Aim to reach agreement for a referral to
Quit 4 Life where a local agreement gives priority to pregnant women. Example of
service user, who attended sessions at local GP practice, successfully quit
smoking and delivered a healthy baby at term.
Considering smoking cessation within the context of the government’s tobacco

control priority is considered. Taking this in isolation it can clearly be seen that the
health visitor reviews are seen to be important by all stakeholder groups, with 88%
of local authority respondents (29% extremely, 34% very, 25% somewhat), 95% of
health service respondents (50% extremely, 25% very, 20% somewhat) and 97% of
health visitor respondents (57% extremely, 25% very, 15% somewhat) indicating
that it is important to some extent. From a statistical perspective, the responses from
the health services stakeholder group cannot be distinguished from those of the
health visitors’ stakeholder group.
In an open letter, representatives of the Royal College of Nursing, the Royal College
of Paediatrics and Child Health, the Royal College of GPs and the Royal Society for
Public Health have reinforced the importance of the health visiting service to
government priorities, including the reduction of obesity and mental health issues in
both adults and children and the promotion of social mobility. They also emphasise
the vital and unique role health visitor’s play in providing support to all families (see
Appendix 8 for more detail).
Safeguarding and child protection
Respondents were asked how important they thought the universal reviews were to
delivering the benefits of the healthy child programme in the areas of safeguarding
and child protection. The question asked was: “How important do you think the
universal health visitor reviews are to delivering the benefits of the Healthy Child
45
Programme 0-5 years in the following areas?” Allowable answers were:

 very important
 not so important
 not at all important
don’t know
The results are shown Table 11 and Figure 11 for safeguarding and in Table 12 and
Figure 12 for child protection.
Figure 11: Importance to escalation of safeguarding concerns
Extremely important Very important Somewhat important Not very important Not at all important Don't know
Local authority (284)
Health services, NHS (290)
Health visitors (3130)
Table 11: Importance to escalation of safeguarding concerns
Importance: Extremely Very Somewhat Not very Not at all Don't know
Local authority (284) 57% 28% 12% 0% 0% 2%
Health, NHS (290)* 89% 8% 3% 0% 0% 0%
Health visitors (3130)* 89% 8% 2% 0% 0% 0%
*Results not statistically significantly different from each other.
Figure 12: Importance to child protection
Extremely important Very important Somewhat important Not very important Not at all important Don't know
Table 12: Importance to child protection
Importance: Extremely Very Somewhat Not very Not at all Don't know
Local authority (284) 54% 32% 11% 0% 0% 2%
Health, NHS (290)* 89% 7% 4% 0% 0% 0%
Health visitors (3130)* 91% 6% 2% 0% 0% 0%
* Results not statistically significantly different from each other

46
The health visitor reviews are seen to be important to safeguarding by all

stakeholder groups, with 98% of local authority respondents (57% extremely, 28%
very, 12% somewhat), 100% of health service respondents (89% extremely, 8%
very, 3% somewhat) and 100% of health visitor respondents (89% extremely, 8%
very, 2% somewhat) indicating that it is important to some extent. From a statistical
perspective, the responses from the health services stakeholder group cannot be
distinguished from those of the health visitors’ stakeholder group.
The health visitor reviews are seen to be important to child protection by all
stakeholder groups, with 98% of local authority respondents (54% extremely, 32%
very, 11% somewhat), 100% of health service respondents (89% extremely, 7%
very, 4% somewhat) and 100% of health visitor respondents (91% extremely, 6%
very, 2% somewhat) indicating that it is important to some extent. From a statistical
perspective, the responses from the health services stakeholder group cannot be
distinguished from those of the health visitors’ stakeholder group.
Only a very small minority (2%) of respondents from local authorities think that the
universal service is not at all important to either safeguarding or child protection.
That the universal health visiting service is important to both safeguarding and child
protection is almost universally agreed, which is consistent with the reasons given
for wanting the mandation to continue in either its current form or in a revised form
(see section on future of mandation) because it ‘safeguards all children’.
The National Network of Designated Health Professionals for Safeguarding

Children (NNDHP), the GP Infant Feeding Network (GPIFN) and the National
Children’s Bureau (NCB) have written to emphasise the importance of the universal
service to safeguarding and child protection (see Appendix 8).
Case study Safeguarding and child protection
Specialist Health Visiting Service Appendix 6, case study L
A local area developed a Specialist Health Visiting service for asylum seekers,
refugees, migrants and travellers. These have complex and diverse needs
including experience of persecution, trafficking, sexual abuse, domestic violence,
mental health issues, sexual exploitation, domestic slavery and female genital
mutilation. Home visits include taking comprehensive past medical history, skills
support as well as English for Speakers of Other Languages. Support is also
given to access GPs, dentists, children’s centres, school and sexual health
services. Specialist health visitors harness partnership working to co-ordinate a
multi-agency response around the family including interpretation services and
response to any safeguarding concerns. They also roll out specialist training to
other health professionals, support workers and staff in children’s centres. Survey
feedback gives the service 10/10 and families report that it has helped them with
47
behaviour, breastfeeding, diet, education, GP appointments and referrals to other

services as well as communications with teachers, social workers and the Home
Office.
Stakeholders were asked if they believed the universal health visitor reviews
delivered a positive return on investment, in other words that they save more money
in the wider system than they cost to deliver. The question posed was: “To what
extent do you believe the universal health visitor reviews deliver a positive return on
investment, ie, these services save more money in the wider system than they cost
to deliver?” Allowable responses were:
 positive (eg save more than they cost)
 neutral (eg save about the same as they cost)
 negative (eg cost more than they could ever save)
don’t know
The results by major stakeholder group are presented in Table 13 and Figure 13.
Figure 13: Responses by stakeholder group to question: “To what extent do

you believe the universal health visitor reviews deliver a positive return on
investment?”
Positive (i.e. save more than they cost) Neutral (i.e. save about the same as they cost) Negative (i.e. cost more than they could ever save) Don't know
Table 13: Responses by stakeholder group to question: “To what extent do

you believe the universal health visitor reviews deliver a positive return on
investment?”
Positive (ie
save more Neutral (ie save Negative (ie cost
than they about the same as more than they could
cost) they cost) ever save) Don't know
Local
authority
(284) 68% 8% 4% 21%
Health
services,
NHS (290) 83% 8% 2% 6%
48
Health
visitors
(3130) 88% 5% 2% 5%
On the whole, all three stakeholder groups believe that the return on investment for
these services is positive, in other words that they save money across the wider
system. Positive responses were 68% for local authorities, 83% for health services
and 88% for health visitors. This is consistent with stakeholder feedback that ‘failure
there will increase pressure on other services’ and ‘saves money in the longer term’.
This belief is held most strongly by those working in the service (the health visitors
themselves (88%) followed by those manging the services and commissioning the
downstream services, the health services (83%). Although the majority of local
authority respondents (68%) believe there is a positive return on investment this is
lower than that for the other stakeholder groups. Among local authority respondents,
21% replied that they did not know if there was a positive return on investment or
not. This is a significant minority and clearly more work needs to be done both to
improve the quality and accessibility of the economic evidence-base and also to
improve the way in which this information is communicated across local authorities.
During 2016-17 PHE commissioned Optimity Advisors to assess evidence on the

effectiveness and cost-effectiveness for health visitors as delivery agents of the
Healthy Child Programme. This work is based on secondary research and evaluates
UK and international evidence covering both universal and targeted services
delivered by health visitors. It is important to note that this assessment of the
evidence is only one part of the wider project (being undertaken by Optimity
Advisors as the preferred provider) that is collating evidence on cost-effectiveness
and return on investment of interventions associated with Best Start in Life. It is
also important to note that the assessment is of the evidence base as described
above; this is not an evaluation of the health visiting service in England.
The main interim conclusion of this part of the project is that there is insufficient
research in this area for any firm conclusions to be drawn. More research needs to
be conducted, especially in the UK setting and also with a stronger focus on longer
term outcomes. More evidence was found for the targeted activities than for the
universal programme. Much of the economic evidence comes from abroad, such as
from the USA. It is uncertain to what extent this might be transferrable to the UK
given the differences in underlying health systems.
The full report will be published by PHE in due course and it will be important to
consider the evidence on health visitors within the wider context of all of the Best
Start in Life interventions under consideration.
49
Service user experience
The results of the service user engagement are detailed in Appendix 7.
It was clear from service user feedback that they valued the health visiting service
but did not, on the whole, know enough about either the service or the health visitors
themselves to make full use of the opportunity. For example, they said they would
be more likely to disclose difficulties such as feeling low or experience of domestic
violence if they had known that health visitors were specialist registered nurses. Also
they would make more use of the health visitors for advice and guidance on minor
illnesses because they would be aware that health visitors would have expertise in
this area and could prescribe medication where required. Service users were also
very pleased to know that they could contact their health visitor out of hours and ask
for extra help if required.
They were positive about

 The antenatal contact and would like more access to education on parenting
so they build confidence in caring for their new baby.
 Support for breastfeeding to help informed choice and to sustain this for
longer but also sensitive handling where they chose not to breastfeed.
 Building a relationship with an individual professional so they felt they could
confide as appropriate and get extra support where needed.
They also recognised the importance of the health visitor role in building community
capacity in support of the cohort of new mothers and fathers, especially peer support
groups to avoid isolation and extend social networks.
Conclusions
The National Health Visitor Programme was announced in 2010 and concluded in
2015. During that time it delivered to the workforce an increase of approximately
4,000 trained health visitors (an increase of around 50%) and transformed the
service using the 4 5 6 model. A review of the mandated aspects of universal
service undertaken in 2016 revealed strong support, from a wide range of
stakeholders, for the service to be reinforced via continued regulation and a high
level of recognition of the importance of the 6 high impact areas to the delivery of
improved outcomes and a view that the service has a positive return on investment,
i.e. that it saves more than it costs in the longer term.
The benefits realisation strategy for this program is embedded within business as
usual and monitored via existing frameworks, such as the Public Health Outcomes
50
Framework and PHE’s Early years Profiles. This combined with intelligence
gathered during the 2016 review of the universal service, a voluntary local authority
data collection on the universal aspects of service and a collection of case studies
and user feedback from the field has enabled a rounded picture of benefits to be
described, then tested and validated by comparing information from multiple
sources and multiple perspectives.
Looking at the most current data it can be seen that the number of pregnant women
receiving a visit during the antenatal period has more than doubled and the
percentage of children receiving the service has increased significantly and
continues to rise. Notably the overall coverage of the new birth visit (delivered both
before and after 14 days) reaching 97.8% of the eligible population between July
and September of 2016.
Tracked outcomes for teenage pregnancy, smoking in pregnancy, low birth-weight

at term, infant mortality, excess weight, hospital admissions for injury and coverage
of the MMR vaccination improved during the programme. Whilst these will have
also been influenced by other factors and initiatives the role of the health visitor in
driving improved outcomes has been exemplified through case studies. These case
studies also suggest that health visitors should be having a positive impact on rates
of A&E attendance and emergency hospital admission but it is possible that these
benefits are overwhelmed by structural factors in the health system as they are
generally increasing across all age groups. The picture on breastfeeding rates
continues to be disappointing and merits attention from a national perspective.
During the programme inequalities in teenage pregnancy, infant mortality,

breastfeeding at 6-8 weeks, A&E attendances, emergency hospital admissions and
hospital admissions for injury were reduced. Where the changes in inequality before
the start of the programme could be compared with the changes in inequality during
the programme some impressive reductions inequality were delivered. In addition
although inequalities in excess weight at 4-5 years were found to be increasing
during the programme these increases were at a much slower rate than the
increases in inequality observed before the start of the programme.
In summary access has improved, a large proportion of outcomes have improved

and for many indicators inequalities have been reduced both in real terms and in
relative terms compared to where they might have been if the pre-program
trajectories had been allowed to continue.
When surveyed stakeholders, including local authority commissioners, NHS service

providers and health visitors themselves, confirmed the importance of universal
health visitor reviews to delivering the benefits of the healthy child programme. How
these population level benefits accumulate over time from the day to day activities of
health visitors, working on an individual and collective basis with children and their
51
families, have been exemplified via case studies for the six high impact areas. In
addition these stakeholder groups are of the opinion, to a greater or lesser extent,
that these services deliver a positive return on investment, they save more money in
the longer terms than they cost to deliver.
Service users report a positive experience as well as support for and interest in
other aspects of service, of which they were previously unaware. It is clear from
their feedback that building relationships is regarded as important and that more
benefit could be gained by taking steps to raise public awareness of the health
visitors role, their status as qualified nurses, their unique position within the
prevention agenda and what families can expect from the service.
52
Appendix 1: Members of PHE’s Best Start in Life

Board
Membership: Best Start in Life Programme Board
Professor Viv Bennett, Chief Nurse, Public Health England (Co Chair)
Phil Norrey, Chief Executive Devon County Council (Co Chair)
Eustace DeSousa, National Lead Children and Young People and Families, Public Health England
(PHE)
Martyn Regan, Centre Director for Yorkshire and Humber, PHE
Sally Burlington, Head of Programme Adults and Children, Local Government Association Sarah
Kincaid, Policy Manager, Department of Communities and Local Government
Julia Gault, Deputy Director Family and Children Maintenance Policy, Department of Work and
Pensions
Helen Stephenson, Child Poverty and Children’s Services Strategy, Department for Education
Nick Adkin, Deputy Director Healthier Lives Division, Department of Health (outgoing)
Dorian Kennedy, Deputy Director Healthier Lives Division, Department of Health (incoming)
Sally Savage, Association of Directors of Children’s Services
Virginia Pearson, Association of Directors of Public Health
Sue Hatton, Senior Nursing Policy Manager, Health Education England
Michelle Mellor, Deputy Director of Nursing, NHS England (outgoing)
Lorraine Mulroney, Nursing Directorate, NHS England (incoming)
Membership: Task and Finish Group

Helen Duncan, Programme Director, National Child and Maternal Health Intelligence Network, PHE (Chair)
Coleen Milligan, Programme Manager, National Child and Maternal Health Intelligence Network, PHE
Kate Thurland, Head of Health Intelligence, National Child and Maternal Health Intelligence Network, PHE
Martyn Regan, Centre Director, PHE
Sue Hatton, Health Education England
Alison Burton, Health and Wellbeing, PHE
Sarah Gaughan, Health and Wellbeing, PHE
Samantha Ramanah, Local Government Association

53
Deepa Patel, Advisor Children’s Public Health, Local Government Association
Paul Ogden, Local Government Association
Juliet Whitworth, Local Government Association
Nicky Brown, Children and Young People’s Lead London, PHE
Sally Savage, Association of Directors of Children’s Services
Virginia Pearson, Association of Directors of Public Health
Wendy Nicholson, Nursing Directorate, PHE
54
Appendix 2: Analytical methodology and

statistical tests
Numbers of health visitors in the workforce
Electronic staff record (ESR)
Provisional health visitor numbers are published monthly by NHS Digital, sourcing data from the ESR.
These are published as NHS Workforce Statistics
digital.nhs.uk/searchcatalogue?topics=0%2fWorkforce&sort=Relevance&size=10&page=1#top
These were used to calculate a monthly health visitor full-time equivalent (FTE) total from the ESR by
summing the field ‘Total FTE’ and restricting records to ones where the field ‘Level’ is ‘006_Health Visitor’.
Independent sector collection
Figures on health visitors working in the independent sector are collected biannually within NHS Digital’s
workforce Minimum Dataset, and are published as experimental statistics. They reflect full time equivalent
staff, however it is recognized that the statistics for Independent Sector Healthcare Providers are a partial
return not covering the whole sector, do not only show the staff providing NHS commissioned services, and
also may include staff on maternity leave and career breaks, for example. Bank and casual staff are
excluded where it is possible to do so.
https://www.gov.uk/government/statistics/announcements/healthcare-workforce-statistics-september-2016
Health visitor minimum data set (MDS)
The MDS was set up to help support the government’s commitment to improve the health visiting service
and recruit more health visitors by 2015. It aimed to collect data from all employers of health visitors
including capturing staff who are not included on ESR. These included those health visitors working for
local authority and social enterprise employers.
data.gov.uk/dataset/health-visitors
The ‘England’ figures in the ‘Number of health visitors’ sheet was used for each month.
Indicative Health Visitor Collection (IHVC)
A parallel collection was run by NHS England between April 2014 and September 2015 for management
information only, in order to provide a more real-time view, and to address some of the known issues with
the MDS data. These figures are published as the Indicative Health Visitor Collection (IHVC):
www.england.nhs.uk/statistics/statistical-work-areas/health-visitors/indicative-health-visitor-collection-ihvc/
The figure in cell D12 of each monthly sheet (Total established1 in workforce FTE) was used as the total
health visitor FTE from the IHVC.
55
Service delivery: summaries from health visitor service delivery metrics overview
Quarterly health visitor service delivery metrics and the associated outcomes have been collected by PHE
from local authorities through a voluntary data collection since quarter 1 2015/16. At each quarterly
collection, the local authority had the option to revise the data from previous quarters.
The 2016/17 quarter 2 data was published on 25 January 2017 for the first time alongside revisions to the
previous quarter. This publication was used to produce a PDF summary for England; an example is shown
below.
Summary of Health Visitor Service Delivery Metrics for Noshire
Overall trends through transfer: Stable with some areas of improvement

Four quarters of 2015/16 (based on quarter 4 submission, data published July 2016)
Indicator Quarter 1 Quarter 2 Quarter 3 Quarter 4 Trend

face-to-face antenatal contact with a Health 75 201 150 115 Not applicable

92.2% 89.7% 89.2% 90.7% No evidence of trend

7.6% 10.1% 10.7% 9.1% Not applicable
C8i: Percentage of 6-8 week reviews completed 85.3% 76.2% 90.4% 90.4% Improving
C8ii: Percentage breastfed at 6-8 weeks 26.5% 23.3% 21.7% 20.8% Deteriorating

reviews completed by the time the child turned 90.7% 91.3% 95.2% 92.0% Not applicable
12 months
reviews completed by the time the child turned 91.4% 91.9% 95.7% 92.4% No evidence of trend
15 months

79.1% 83.4% 81.8% 91.8% Improving
completed

completed using ASQ-3 (Ages and Stages 54.6% 74.0% 51.1% 70.8% Improving
Questionnaire)
Shaded pink cells denote values from un-validated data
Data collection
Local authorities were asked to report data items quarterly for the following indicators, for their residents:
 number of mothers who received a first face to face antenatal contact with a health visitor at 28 weeks
or above
 percentage of New Birth Visits (NBVs) completed within 14 days and after 14 days
56
 percentage of 6-8 week reviews completed by age 8 weeks

 percentage breastfeeding at 6-8 weeks
 percentage of 12-month development reviews completed by the time the child turned 12 months
 percentage of 12-month development reviews completed by the time the child turned 15 months
 percentage of 2-2½ year reviews completed by age 2½
 percentage of 2-2½ year reviews completed using ASQ-3 (Ages and Stages Questionnaire)
These were submitted to PHE via a web-based system created and managed by the Local Government
Association (LGA). Validation was applied as figures were entered to prevent straightforward errors such
as reversing the numerator and denominator. Percentages were calculated and displayed by the entry
system as figures were entered as a further sense check against local calculations. An option of entering
‘DK’ was available where a figure was not known.
The system was available during pre-set ‘collection windows’. These opened approximately two months
following the end of the quarter, and stayed open for data entry for just under one month. During this time,
areas could input data and amend data they had previously submitted. Once the collection window closed,
the LGA provided the final dataset to PHE.
Data reporting
On receipt of the data, PHE applied a series of validation steps for each indicator to the local authority
data, details of which can be found in the statistical publication. If the data items passed all validation,
then an indicator value and confidence intervals were calculated and published. If not, the numerator and
denominator were shown, with colour coding showing the reasons for each validation failure.
Indicators were calculated for PHE Centres and for England, with numerators and denominators for these
being aggregates of their constituent areas which passed the initial, basic validation (valid numerator and
denominator). The same further validation as applied to local authority areas was also applied to PHE
Centres and to England, with values and confidence intervals only being published if validation was
passed. The statistics were published as excel files, with accompanying statistical commentary, and are
available at www.chimat.org.uk/transfer#3
Calculation of trends for service delivery metric summaries
The PDF summaries showed the quarterly data from the publication. In the cases where a valid numerator
and denominator had been provided but the data had failed validation (and therefore a value had not been
published), for the purposes of these summaries only, a value was calculated and displayed. Data which
failed validation is highlighted in pink. For the purposes of producing the statistics, it was important to apply
rigorous validation rules to the data provided and be able to demonstrate that the overall publication met
certain data quality standards. For the summaries, it was more meaningful to reflect back to local areas the
data they had provided, which had been subject to local validation and signed off at director level within the
organisation.
57
Trends over time
In addition, the summary describes an indicator trend during the six quarters shown. This was calculated
using a statistical test called the chi-squared test. The test takes the six quarters’ data and tests for
differences over time. It describes whether a trend is going up or down, weighting later data more heavily
than earlier data.
It is noted that running the test on six data points was robust as a minimum of five would usually be
recommended. The test produces two statistics each time it is run:
 the 2 value, which is compared to a pre-defined threshold to determine significance. The

threshold chosen is arbitrary but two commonly accepted levels of significance in statistics are
the 95% level and the 99.8% level, with the 99.8% level implying increased certainty that any
significance found is not down to chance.1 The 99.8% threshold was chosen in this case, in
order to be almost certain that any deterioration in one or more indicators was reflective of a
‘real’ deterioration in the service in that area, rather than a statistical fluctuation
 The second statistic is the ̂ value which describes the slope of the trend. Where the 2 value
indicated a significant trend, ̂ was used to ascertain whether the trend was increasing or
decreasing. The description of the trend for the indicator was therefore one of the following:
o improving: where the 2 value indicated a significant trend and the ̂ showed an upward
slope
o deteriorating: where the 2 value indicated a significant trend and the ̂ showed a
downward slope
o no evidence of trend: where the 2 value did not indicate a significant trend
o insufficient data: where fewer than four quarters of data were available
Trends were calculated for each of the four indicators which track the mandated elements of the universal
health visiting service, and their associated outcomes. For antenatal visits, due to the difficulties in defining
a denominator, only the total number of antenatal visits could be shown so no statistical tests could be
carried out). Thus, a trend could be derived for the following:
 C2: Percentage of New Birth Visits (NBVs) completed within 14 days (service delivery)
 C8i: Percentage of 6-8 week reviews completed (service delivery)
 C8ii: Percentage breastfed at 6-8 weeks (outcome indicator)
 C5: Percentage of 12-month development reviews completed by the time the child turned 15 months
(service delivery)
 C6i: Percentage of 2-2½ year reviews completed (service delivery)
C6ii: Percentage of 2-2½ year reviews completed using ASQ-3 (Ages and Stages Questionnaire)
(outcome indicator)
Overall trend
1
By definition 1 in 20 findings will be incorrectly considered significant when the threshold is set at 95%; at 99.8% this decreases to
one in 500.
58
The four trends relating to service delivery were then combined to ascertain an overall description of how
effectively the service as a whole had been maintained throughout the transfer of commissioning
responsibilities (“Overall trends”) and beyond. The options for this overall assessment were as follows (the
logic was applied in the order shown):
 deterioration of one or more mandated elements: If any of the four service delivery metrics
amenable to trend analysis (C2, C8i, C5, C6i) showed as ‘deteriorating’, then the service as a whole
was assessed to have not been maintained.
 insufficient data: If any of the four service delivery metrics was assessed as 'insufficient data', then
there was insufficient data to assess whether the service as a whole has been maintained
 stable: If all four service delivery metrics showed ‘no evidence of trend’
 stable with some areas of improvement: One or two service delivery metrics assessed as
‘improving’, with the other three or two metrics assessed as ‘no evidence of trend’
 improving: All four service delivery metrics assessed as ‘improving, or three areas assessed as
‘improving’, with the other metrics assessed as ‘no evidence of trend’
Health outcomes: From PHE’s early years’ profiles
PHE’s Early Years Profiles are designed to help commissioners and providers of health visiting services to
assess the priorities for and outcomes of the transformation of health visiting services. The profiles were
developed during the National Health Visitor Programme to support post programme evaluation and
benefits realisation. They show at a glance how each local area performs against key indicators for
outcomes that are potentially influenced by the universal health visiting service. They provide useful
background information and context to current activity levels and outcomes.
It is important to note that the profiles display annual indicators, and because of the associated time lag,
the majority of the indicators contained within the current profiles relate to period before the transfer of
commissioning of children’s public health in October 2015, i.e. to the period of the transformation
programme.
The indicators in the profiles are drawn from many sources, and detailed metadata is available from the
interactive profiles, using the link above. Details of the indicators can be found in the information guidance
published for the transfer in October 2015, which describes commissioning data for 0-5 public health:
www.gov.uk/government/publications/0-to-5-public-health-services-transfer-of-commissioning
A coloured trend arrow is available on the profiles to describe recent trends in the indicator. The
methodology for the trend arrow is the same chi-squared test as described for the service delivery metrics.
This test was applied to as many annual data points as were available in the profiles to describe a ‘recent
trend’; again, the most recent data points were weighted most heavily.
1. Calculation of indicators by national deprivation decile and calculation of inequality ‘gap’
59
For the following indicators (group 1), record-level data was available, allowing records to be assigned to a
deprivation decile based on the IMD 20152 average score of the lower layer super output area (LSOA11)
relating to the child’s postcode of residence. The average score for the LSOA was used to rank them and
then they were divided into deciles based on rank.
 Infant mortality
 Excess weight in 4-5 year old children
 A&E attendances in children under 5 years
 Emergency hospital admissions in children under 5 years
 Admissions for injuries for children under 5 years
For the following indicators (group 2), record-level data was not available, and therefore deprivation deciles
were calculated based on assigning lower-tier local authorities (or upper-tier local authorities where the
data were not available at lower-tier level) to deciles, based on their IMD 2015 rank (based on the average
score).
 Breastfeeding prevalence at 6-8 weeks

 Smoking at time of delivery
 Under 18 conceptions
 Low birthweight of term babies
The indicator rates for each decile were calculated and plotted as a bar chart for each year considered. For
each year, the inequality gap between the rates for the children living in the most deprived decile and the
rate for children living in the least deprived decile was calculated.
7.2
7
6 5.8 5.7
Rate per 1,000 live births
5 4.8
4.1
4 3.8
3.7
3.2 3.1 3.0
3
0
1 (Most 2 3 4 5 6 7 8 9 10 (least
deprived) deprived)
LSOA deprivation decile in England (IMD 2015)
Figure: Chart showing gap calculation, using the example of infant mortality rate in 2008. The ‘gap’
between the most deprived and least deprived decile is therefore 7.2 - 3.0 = 4.2.
2
For the indicator of excess weight in children aged 4-5 years IMD 2010 scores were used.
60
The indicator values of the most and least deprived were plotted for each year to show the change in the
gap over time.
6
Most deprived decile
Infant mortality rate
4.4
4.2
5 2.9
4.0
2.8
3.5 3.1 2.9
3.8 2.3
4
3
Least deprived decile
0
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Figure: Chart showing change in gap in infant mortality rates over time between people living in the least
and most deprived areas of England.
2. Calculation of inequality ‘gradient’ and interpretation of change over time
For each year, an inequality gradient was calculated, and the exact method used to do this depended on
whether the indicator deciles were calculated from underlying record level data (group 1 indicators, listed
above) or from local authority level data, aggregated (group 2 indicators).
For group 1 indicators, the gradient of inequality for each year was described using the slope index of
inequality (SII), calculated using the SII tool3. It calculates the ‘line of best fit’ for the bar chart, but then
adjusts it to take into account the distribution of the indicator denominator within the ten deciles. It is
possible to do this because the underlying data source is at record level.
3
The SII tool was developed by the Public Health England Knowledge and Intelligence Teams in the East Midlands and London.
More information, including a link to a worked example in Excel can be found here:
www.apho.org.uk/resource/item.aspx?RID=132634
61
6
0
1 2 3 4 5 6 7 8 9 10
(Most (least deprived)
deprived) LSOA deprivation decile in England (IMD 2015)
Figure: Chart using the example of infant mortality rate in 2008, showing the slope index of inequality with
gradient -0.48.
For group 2 indicators, the line of best fit was calculated and plotted onto each bar chart, using the in-built
Excel functions SLOPE and INTERCEPT. The gradient of that best fit line was considered to be the
gradient of inequality.
4%
3%
Low birthweight of term babies
2%
1%
0%
1 2 3 4 5 6 7 8 9 10
(Most deprived) (Least
County & UA deprivation decile in England (IMD 2015)
deprived)
Figure: Chart using the example of percentage of babies born at term with low birthweight in 2012, showing
the standard line of best fit with gradient -0.15.
A comparison between the two different methods for calculating inequality gradient was carried out on two
selected indicators (A&E attendances under 5 years and emergency hospital admissions under 5 years) in
order to test the validity of drawing conclusions from both. The magnitude and direction of the change in
62
inequality gradient was found to be comparable between the two methods, with the population weighting
applied by the SII methodology contributing to the small differences in value.
Over the whole period considered, the inequality gradients calculated for each year were plotted as a line
chart in order to more accurately describe the trend of inequalities over time. These can be plotted as either
positive or negative values; a trend towards zero is desirable as it indicates a ‘flattening’ of the gap.
5
4.8
4.6
4.1
4
3.9
3.6
3.5
3.3 3.3
Slope index of inequality
3.1
3 3.0
0
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Figure: Chart using the example of infant mortality rate showing the inequality gradients (calculated using
the SII for this indicator) for each year.
Linear trend lines were calculated and drawn (using the in-built Excel functions SLOPE and INTERCEPT)
over the inequality gradient up to 2010 (or 2010/11 for indicators that are calculated for financial years) and
also after 2010 (including 2010 itself). Where available, the pre-2010 linear trend line was extended to
model what would have happened to inequalities relating to deprivation if the pre-2010 trend had continued.
4.62
4
3.65
3.58
3 3.08
2.28
2
0
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Trend pre-2010 Trend post-2010 Continuation of pre-2010 trend
63
Figure: Chart using the example of infant mortality rate showing the inequality gradients for each year. The
numerical labels on the chart indicate the ‘smooth’ trend value at key points.
These values were then used to calculate and describe the overall changes. So in the above example,
where the actual change in inequalities after 2010 is shown by the light grey line and the continuation of the
pre-2010 trend is shown by the dashed line:
 On average inequalities have improved between 2010 and 2015 by 15.7% (the percentage fall from
3.65 to 3.08, based on the unrounded figures)
 However it can be seen from the slope of the lines that the improving in inequality was more rapid prior
to 2010, and in fact the gradient on average improved between 2006 and 2010 by 22.5% (the
percentage fall from 4.62 to 3.58).
 Continuation of the pre-2010 trend is shown with the dashed line. It is shown that had inequalities
continued to improve at pre-2010 rates, the current inequality gradient would actually be at 2.28 rather
than 3.08 – that is, current levels of inequality are about 35% worse than they otherwise would have
been.
Stakeholder views: Quantitative analysis of survey responses
Views of a wide range of stakeholders on the future of the mandation were gathered using an online
survey which ran from 29 June 2016 to 31 July 2016. This covered local leadership arrangements, views
on mandation, commissioning intentions, benefits realisation and general comments on sustainability. The
questions included in the survey and their wording were explored and approved through PHE’s Best Start
in Life Board. A full list of the survey questions can be found in Appendix 3. One of the first questions of the
survey asked for the respondent’s job role. The selection was restricted to one of the following:4
 local authority chief executive – local authority
 director of public health – local authority
 director of children’s services – local authority
 local authority lead member for children & young people – local authority
 local authority health & wellbeing board chair – local authority
 local authority portfolio holder for public health – local authority
 local authority commissioner – local authority
 CCG commissioner – health services, NHS
 provider of health visiting services (management) – health services, NHS
 health visitor (health visitor team) – health visitor
Not all questions were relevant to all respondent types, and so the system used the answer to this question
to conditionally select the ‘path’ through the survey (this is also shown in Appendix 3). Once the survey had
closed, the survey results were extracted and analysed. The respondent job roles, described above, were
grouped into more general groups of ‘local authority’, ‘health services, NHS’ or ‘health visitors’, and were
used to separate out responses, in order to allow for meaningful analysis, and to differentiate between key
stakeholder groups.
For each question, the analysis split out the responses for each of the three respondent groups. A
statistical test was run to establish whether the groups gave significantly different answers to the
questions, as would be expected. This test, known as Kruskal–Wallis one-way analysis of variance is a
4
Based on the Department of Health requirements for the review.
64
method for testing whether data provided from different groups are in fact significantly different from each
other.
Where the Kruskal–Wallis test indicated there were significant differences, a further statistical test, Dunn's
test, was applied in order to establish the detail of exactly which respondent groups gave statistically
different responses. For example, in the table shown below (Table 9c in the report), the local authority
responses are significantly different from the other two respondent groups, but they themselves are not
significantly different from each other. 44% of local authority respondents said the reviews were ‘extremely
important’ for transition to parenthood – smoking cessation, and this is significantly lower than the other
respondent groups. However, although 70% of health visitors said the reviews were ‘extremely important’
for transition to parenthood – smoking cessation, this is not significantly higher than the 66% of
respondents from the ‘Health service, NHS’ group.
Table example: Importance of the 0-5 universal reviews for transition to parenthood – advice and
guidance on smoking cessation in pregnancy and to reduce harm to baby from second hand smoke
(tobacco control priority)
Importance: Extremely Very Somewhat Not so Not at all Don't know
Local authority (243) 44% 36% 14% 3% 0% 2%
Health services, NHS (290)* 66% 23% 9% 1% 0% 1%
Health visitors (3130)* 70% 22% 6% 1% 0% 0%
* Results not statistically significantly different from each other
The open-source statistical environment R was used to run these tests.
All the results are displayed in the report as tables (showing rounded figures for ease of
interpretation) and charts (derived from the unrounded percentages).
65
Appendix 3: Stakeholder survey: questions and

intended audience
QUESTION RESPONSES LA Chief DPH, CCG Health
Exec, DCS, Comnr,
Visitor
H&WBB LA Service
Chair, Comnr Provider (Team)
LA elected
member,
LA
portfolio
holder
Background
Please tell us about your role. Are you giving us your views from the  local authority chief Yes Yes Yes Yes
position of executive
 director of public health
 director of children’s
services
 local authority lead
member for children &
young people
 local authority health &
wellbeing board chair
 local authority portfolio
holder for public health
 local authority
commissioner
 CCG commissioner
 provider of health visiting
services (management)
 health visitor (health
visitor team)
Please tell us which area of the country you work in  drop down list of all PHE Yes Yes Yes Yes
centre
areas/Government Office
Regions
Leadership
Within your Local Authority which Director is responsible for children’s  director of Public Health Yes Yes No No
public health 0-5 years?  director of Children’s
Services
 other
 don’t know
If other please specify Free text field Yes Yes No No
Within your Local Authority which elected member is responsible for  lead member for Yes Yes No No
children’s public health 0-5 years? Children & Young People
 portfolio holder for
public health
 other
 don’t know
If other please specify Free text field Yes Yes No No
Mandation
Existing legislation, mandating the five universal health visitor reviews  the mandation is Yes Yes Yes Yes
(antenatal, new baby, 6-8 weeks, 1 year and 2-21/2 years) are delivered extended in its current
66
for every child, is due to expire at the end of March 2017. What would form
you recommend happens next?  the mandation is
extended but in a revised
form
 the mandation is allowed
to expire as planned
 don’t know
What are your reasons for this recommendation? Free text field Yes Yes Yes Yes
If you are recommending that the mandation is extended in a revised Free text field Yes Yes Yes Yes
form what changes would you like to see and why?
Do you consider the mandated checks for 0-5s more or less important Yes Yes No No
 more important
for your local population's health and wellbeing than the other Public
Health mandated functions?  less important
 neither more or less
Note: Other mandated Public Health functions include National Child
Measurement Programme, NHS Health Checks, Sexual Health Services, important
Public Health advices and Health protection  don’t know
What are your reasons for your response? Free text field Yes Yes No No
Commissioning/ Commissioning intentions/Service levels
In your area how did service levels for the five universal health visitor  improved Yes Yes Yes Yes
reviews change last year? (2015/16)  stayed the same
 deteriorated
 don’t know
In your area how will service levels for the five universal health visitor  improve Yes Yes Yes Yes
reviews change this year? (2016/17)  stay the same
 deteriorate
 don’t know
In your area how do you expect service levels for the five universal  improve Yes Yes Yes Yes
health visitor reviews to change next year? (2017/18)  stay the same
 deteriorate
 don’t know
How confident are you that the introduction of new service models,  extremely confident Yes Yes Yes Yes
including the integration of services, has enabled you /will enable you  very confident
to commission for/deliver better outcomes?  somewhat confident
 not so confident
Note: You will be invited at the end of the survey to provide contact  not at all confident
details if you would like to share examples of good practice with the  don’t know
review team.
What impact do you expect future service models for children’s public  require more health Yes Yes Yes Yes
health will have on the health visiting workforce? visitors
 require about the same
number of health visitors
 require fewer health
visitors
 don’t know
Please tell us about any future commissioning intentions Free text field Yes Yes No No
Please tell us how you have addressed any boundary issues (registered Free text field No Yes No No
versus resident population)
Benefits realisation
How important do you think the universal health visitor reviews are to For each No Yes Yes Yes
delivering the benefits of the Healthy Child Programme 0-5 years in the
following areas?
 very important
a) Transition to parenthood – supporting the parents, providing  somewhat important
advice and guidance healthy lifestyle and preparing the  not so important
67
home for the new baby  sot at all important

 don’t know
b) Transition to parenthood –contraceptive and sexual health

advice to support planned pregnancies or parenthood
c) Transition to parenthood – advice and guidance on smoking

cessation in pregnancy and to reduce harm to baby from
second hand smoke (tobacco control priority)
d) Transition to parenthood – advice and guidance on

establishing secure attachment and bonding, home learning
environment
e) Maternal mental health – assessment, brief intervention and

signposting to other support services; being mindful of
paternal wellbeing and good mental health as a mechanism
for supporting healthy relationships
f) Breastfeeding – advice, education and practical support,

including signposting to other support services in order to
initiate and sustain breastfeeding (childhood obesity priority)
g) Healthy weight – advice and education on nutrition,

weaning, healthy eating (including access to means tested
vouchers for fresh fruit, vegetables and vitamins) and
physical activity (childhood obesity priority)
h) Managing minor illnesses & accident prevention – advice &

guidance, illness escalation approaches, support uptake of
childhood immunisations, home safety environment
i) Healthy 2 year olds and school readiness – safety net on

new-born and infant screening, child development
assessment aged 2 – 21/2 years, supporting parents to
articulate development concerns (special needs) with access
to early help, onward referral to other services (paediatrics,
speech and language etc.)
How important do you believe the universal health visitor reviews are For each Yes Yes Yes Yes
to delivering the wider benefits of child health and wellbeing in the
following areas?
 very important
 not very important
a) Escalation of safeguarding concerns  not at all important
 don’t know
b) Child protection
To what extent do you believe the universal health visitor reviews  positive (e.g. save more Yes Yes Yes Yes
deliver a positive return on investment? I.e. these services save more than they cost)
money in the wider system than they cost to deliver.  neutral (e.g. save about
the same as they cost)
 negative (e.g. cost more
than they could ever
save)
 don’t know
General Comments
68
Please let us have any other comments on the sustainability of these Free text field Yes Yes Yes Yes
services. In particular what are the main risks, mitigating actions and
opportunities for innovation?
69
Appendix 4: Early years profiles - trends in

outcomes
Under 18 conceptions
40
35
Rate per 1,000 women aged 15-17
30
25
20
15
10
0
2010 2011 2012 2013 2014
70
Smoking status at time of delivery

15
12
9
%
0
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
Low birth weight of term babies

3
2.5
2
%
1.5
0.5
0
2010 2011 2012 2013 2014 2015
71
Infant mortality
5
4
0
2010 2011 2012 2013 2014 2015
Breastfeeding prevalence at 6-8 weeks after birth

50
45
40
35
30
%
25
20
15
10
0
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
72
Reception: Prevalence of overweight (including obese)

25
20
15
%
10
0
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
A&E attendances (0-4 years)

600
550
500
450
Rate per 1,000 population
400
350
300
250
200
150
100
50
0
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
73
Emergency admissions (aged 0-4)

160
140
120
100
80
60
40
20
0
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
Hospital admissions for accidental and deliberate injuries in children

160
(aged 0-4)
140
120
100
80
60
40
20
0
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
74
Population vaccination coverage - MMR for two doses (5 years old)

100
80
60
%
40
20
0
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
75
Appendix 5: Trends in inequalities

Please note values are rounded in display; unrounded values have been used in the calculations
1. Detailed charts of gap and gradients

Infant mortality:
8
6
4.4
4.2
5 2.9
4.0
2.8
3.5 3.1 2.9
3.8 2.3
4
3
0
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
4.62
4
3.65
3.58
3 3.08
2.28
2
0
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Trend pre-2010 Trend post-2010 Continuation of pre-2010 trend
76
Teenage conceptions:
70
60
Conception rate per 1,000 aged 15-17 years
50
32.5
30.9 30.9
29.6 29.4 30.3 31.9 30.6 29.9
29.1
40 24.9
25.5
22.8
19.2
30
17.5
15.0
14.9
20

10
0
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
0.00
-0.50
Inequality gradient (based on upper-tier authority deciles)
-1.00
-1.54
-1.50
-2.00
-2.46
-2.50
-2.63
-3.00
-3.29 -2.96
-3.50
-4.00
-4.50
Trend post-2010 Trend pre-2010 Continuation of pre-2010 trend
77
Smoking in pregnancy:
16

14
5.1 4.5
12
6.7
5.5 6.2
6.5
% smoking at time of delivery
10

6
0
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16

Inequality gradient (based on lower-tier authority deciles)
-0.2
-0.56
-0.6
-0.64
-1.0
78
Low birthweight of term babies
4.5

3.5
1.7 1.6
1.6 1.6 1.4
3 1.3 1.4
% Low birthweight of term babies
1.3 1.3 1.3 1.3
2.5

2
1.5
0.5
0
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
0.00
Inequality gradient (based on upper-tier authority deciles)
-0.05
-0.10
-0.10
-0.15
-0.15
-0.15
-0.20
-0.20
-0.25
Trend post-2010 Trend pre-2010 Continuation of pre-2010 trend
79
Breastfeeding at 6-8 weeks
60
50 Least deprived decile

12.3 12.6 9.6
12.3
7.7
6.5
40 Most deprived decile

% breastfeeding at 6-8 weeks
30
20
10
0
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
1.6
Inequality gradient (based on lower-tier authority deciles)
1.2 1.15
0.8
0.74
0.4
0.0
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
80
Excess weight at 4-5 years
30
25
6.8 7.2
6.4 7.7 8.3
7.9 8.4 9.4
8.3
20
Excess weight in Reception - %

15
10
0
2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
12
11 11.08
10
9.38
9 8.71
8 8.42
7.29
7
0
2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
Trend pre-2010 Trend post-2010 Continuation of
pre-2010 trend
81
A&E attendances under 5 years
800

700
600
290.9
309.9 288.9
A&E attendance rate
314.2 289.5
500
294.6
264.1
280.7
400
278.9
300
200
100
0
2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
350 343.1
332.4
325.5 321.5
321.3
300
250
200
150
100
50
0
2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
pre-2010 trend
82
Emergency hospital admissions under 5 years
250
200
Emergency hospital admissions rate
84.7 57.3
81.3 77.9 69.6
150 85.4 77.9 71.7 64.5 61.8

100
50
0
2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
100
80 84.22 77.25
76.36
66.54
60
53.29
40
20
0
2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
pre-2010 trend
83
Hospital admissions for injuries under 5 years
250
Emergency hospital admissions for injuries rate
200
85.8 80.5
150 82.1
75.0 61.4
88.1 66.8 61.6
85.8 88.0
100 Least deprived decile
50
0
2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
100
87.53
83.18
80
82.28
75.71
60
57.36
40
20
0
2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
pre-2010 trend
84
Tooth decay
Source:
National Dental Epidemiology Programme for England:

oral health survey of five-year-old children 2015
85
MMR coverage at 5 years
School readiness
86
The dark line at the bottom of the shaded area shows the proportion of children eligible for free school meals who achieved a good level of development.
The lighter line at the top shows the proportion of children not eligible for free school meals who achieved a good level of development.
87
2. Summary table – inequality gaps

Most deprived decile Least deprived decile
Indicator Year value value Gap
1998 63.6 31.1 32.5
1999 60.8 29.9 30.9
2000 60.4 29.5 30.9
2001 58.7 29.0 29.6
2002 57.7 28.4 29.4
2003 58.2 28.0 30.3
2004 59.1 27.2 31.9
2005 58.2 27.6 30.6
Teenage pregnancy 2006 56.4 27.3 29.1
2007 57.1 27.2 29.9
2008 51.9 27.0 24.9
2009 49.7 24.2 25.5
2010 45.2 22.4 22.8
2011 40.7 21.5 19.2
2012 36.6 19.1 17.5
2013 31.8 16.8 15.0
2014 30.2 15.4 14.9
2006 7.5 3.1 4.4
2007 6.7 2.7 4.0
2008 7.2 3.0 4.2
2009 6.4 3.5 2.9
2010 6.1 2.3 3.8
2011 6.1 2.6 3.5
2012 5.9 3.1 2.8
2013 5.4 3.0 2.3
2014 5.8 2.7 3.1
2015 5.7 2.8 2.9
2010/11 15.1 8.4 6.7
2011/12 15.0 9.9 5.1
2012/13 14.5 10.0 4.5
Smoking in pregnancy
2013/14 13.8 8.3 5.5
2014/15 14.2 8.0 6.2
2015/16 13.9 7.4 6.5
2005 4.0 2.4 1.7
2006 3.9 2.3 1.6
2007 4.0 2.4 1.6
2008 3.9 2.3 1.6
2009 3.7 2.4 1.4
Low birthweight at term 2010 3.6 2.3 1.3
2011 3.7 2.3 1.3
2012 3.6 2.3 1.3
2013 3.6 2.3 1.4
2014 3.6 2.3 1.3
2015 3.6 2.3 1.3
2010/11 40.8 53.1 12.3
2011/12 42.4 54.7 12.3
Breastfeeding at 6-8 2012/13 42.7 55.3 12.6
weeks 2013/14 43.8 53.4 9.6
2014/15 40.5 47.0 6.5
2015/16 41.6 49.3 7.7
2007/08 25.2 18.8 6.4
2008/09 25.6 18.8 6.8
2009/10 26.2 18.9 7.2
2010/11 25.9 18.2 7.7
Excess weight at 4-5
2011/12 26.2 18.0 8.3
years
2012/13 25.5 17.6 7.9
2013/14 25.0 16.7 8.3
2014/15 25.5 17.1 8.4
2015/16 26.2 16.8 9.4
88
2007/08 529.2 250.3 278.9

2008/09 562.5 281.8 280.7
2009/10 583.6 319.5 264.1
2010/11 633.3 338.7 294.6
A&E attendances under
2011/12 669.8 355.6 314.2
5 years
2012/13 690.6 380.7 309.9
2013/14 666.9 377.4 289.5
2014/15 679.8 390.9 288.9
2015/16 728.8 437.9 290.9
2006/07 192.1 106.8 85.4
2007/08 186.3 108.4 77.9
2008/09 194.8 113.5 81.3
2009/10 192.5 114.6 77.9
Emergency hospital
2010/11 200.6 115.9 84.7
admissions under 5
2011/12 185.0 113.4 71.7
years
2012/13 188.0 118.4 69.6
2013/14 180.0 115.5 64.5
2014/15 179.2 117.4 61.8
2015/16 184.1 126.8 57.3
2006/07 179.9 94.1 85.8
2007/08 180.4 92.4 88.0
2008/09 182.9 94.8 88.1
2009/10 191.6 109.5 82.1
Hospital admissions
2010/11 197.6 111.8 85.8
for injuries under 5
2011/12 196.9 116.5 80.5
years 2012/13 174.0 107.1 66.8
2013/14 184.4 109.4 75.0
2014/15 175.0 113.6 61.4
2015/16 169.1 107.5 61.6
89
5
3. Summary table – inequality gradients
Indicator Method Inequality Inequality Value of Value of Pre-prog Value of Value of Post-2010 Value of Comparison of
used to gradient gradient pre-2010 pre-2010 change in post- post-2010 change in continued latest
calculate pre-2010 post-2010 trend line trend level of 2010 trend line level of pre-2010 inequality with
inequality (solid dark line at inequality trend line at latest inequality trend line value based on
gradient grey line) 2010 or (solid post-2010 (dashed continuation of
at starting 2010/11 light grey data point dark grey pre-2010 trend
pre-2010 line) at line) at latest line
data point 2010 or post-2010
2010/11 data point
Teenage Line of best 0.08 0.23 -3.29 -2.96 10.0% -2.46 -1.54 (in 34.7% -2.63 40% better (
conception fit based on narrowing narrowing (in 2006) reduction 2014) reduction -1.54 compared
rate deprivation (from (from to -2.63)
scores at -3.29 to -2.46 to
upper-tier -2.96) -1.54)
LA level
Smoking in Line of best N/A -0.01 N/A N/A N/A -0.56 -0.64 (in 13.1% N/A N/A
pregnancy fit based on widening 2015/16) increase
deprivation (from
scores at -0.56 to
lower-tier LA -0.64)
level
Low SII based on 0.01 0.00 -0.20 (in -0.15 25.3% -0.147 -0.154 (in 5.0% -0.097 60% worse
birthweight at deprivation narrowing widening 2005) reduction (shown to 2015) increase (-0.154
term scores at (from three (from compared to -
LSOA level -0.20 to decimal -0.147 to 0.097)
-0.15) places to -0.154)
clarify)
Infant mortality SII based on 0.26 0.11 4.62 3.58 22.5% 3.65 3.08 (in 15.7% 2.28 35% worse
rate deprivation narrowing narrowing (in 2006) reduction 2015) reduction (3.08 compared
scores at (from 4.62 (from 3.65 to 2.28)
LSOA level to 3.58) to 3.08)
* Positive numbers represent a widening of the gap; negative numbers a narrowing. Gradient values should not be compared between indicators
90
Breastfeeding Line of best N/A 0.08 N/A N/A N/A 1.15 0.74 (in 35.8% N/A N/A
at 6-8 weeks fit based on narrowing 2015/16) reduction
deprivation (from 1.15
scores at to 0.74)
upper-tier
LA level
Excess weight SII based on 0.47 0.19 7.29 (in 8.71 19.5% 8.42 9.38 11.4% 11.08 15% better
at 4-5 years deprivation widening widening 2007/08) increase increase (9.38 compared
scores (from 7.29 (from 8.42 to 11.08)
(IMD2010) to 8.71) to 9.38)
at LSOA
level
A&E SII based on 1.39 4.32 321.3 (in 325.5 1.3% 343.1 321.5 (in 6.3% 332.4 3% better
attendances deprivation widening narrowing 2007/08) increase 2015/16) reduction (321.5
under 5 years scores at (from 321.3 (from 343.1 compared to
LSOA level to 325.5) to 321.5) 332.4)
Emergency SII based on 1.96 4.79 84.22 (in 76.36 9.3% 77.25 53.29 (in 31.0% 66.54 20% better
hospital deprivation narrowing narrowing 2006/07) reduction 2015/16) reduction (53.29
admissions scores at (from 84.22 (from 77.25 compared to
under 5 years LSOA level to 76.36) to 53.29) 66.54)
Hospital SII based on 1.31 5.16 87.53 (in 82.28 6.0% 83.18 57.36 (in 31.0% 75.71 25% better
admissions for deprivation narrowing narrowing 2006/07) reduction 2015/16) reduction (57.36
injuries under scores at (from 87.53 (from 83.18 compared to
5 years LSOA level to 82.28) to 57.36) 75.71)
91
Appendix 6: Case study examples

Case studies are generated by professionals on an ongoing basis. These are important from a
professional development perspective both at an individual level and a service level. It is the
mechanism by which health visitors share best practice across the country by detailing what they
have, in their own experience, found to work. The quality of the case studies and the extent to
which they have been externally validated is variable.
The case studies collected here can be mapped onto the 4 5 6 model of service as follows:-
4 levels of Case 5 Case study 6 high Case

service Study universal examples impact areas study
examples health examples
reviews
Community Q Antenatal K Transition to H, J, K, M,
parenthood N
Universal M, E, N New baby J, E Maternal A, B , Q
mental health
Universal Plus 6-8 weeks I, N Breastfeeding E, P
Universal L 1 year Healthy F
Partnership weight
Plus
2-21/2 H, O Managing C, D,P
years minor
illnesses &
accident
prevention
Healthy 2 G, H, O
year olds &
school
readiness
Case study A
Assessing and supporting a mother with postnatal depression
Author
Charlotte Keane Health Visitor – Bridgewater Community Healthcare NHS Foundation Trust
Date
28 September 2016
What problem / issue was identified
A 35 year old mother of a one year old child was seen at home.
92
During the home visit the Health visitor noted that the mother had poor eye contact with her
baby and looked down a lot. In addition the home environment was not maintained well. The
health visitor explained her role with regards to maternal mental health and the mother
explained her history of being bullied at school which had led to self-harming and low self-
esteem. Whilst the mother was not currently self-harming she did find it difficult to build
relationships and felt isolated in her community.
What happened / intervention
The health visitor undertook a mental health assessment using two different assessment
tools (Edinburgh Post Natal Depression Scale and Generalised Anxiety Disorder
Assessment). The results highlighted low mood in need of monitoring and support and high
anxiety levels. The health visitor discussed with the mother the need to address her own
mental health needs to enable her to meet her child’s needs. The mother was also advised
to interact with other mothers with similar circumstances to increase her confidence and
reduce isolation.
The health visitor introduced and supported the mother to attend a new service called Time
for Me, a creative group for women experiencing anxiety or depression in the antennal and
/or post-natal period. The mother attended these sessions on a weekly basis, whilst the
health visitor continued to monitor her wellbeing and offer support with parenting.
The short and long term improvement
The mother reported feeling relaxed in the sessions enabling her to talk more freely with
peers and empowered her to give herself time out to consider her own needs and away from
daily life. Her child was introduced to the crèche facilities which showed the mother how
independent her child could be and how she thrived from playing with her peers.
Edinburgh Post Natal Depression Scale and Generalised Anxiety Disorder Assessment
scores have improved and the mother has agreed to a referral for a two year funded place
for her child.
What feedback was received
The mother reported that the sessions improved her mood and increased her energy levels
and enthusiasm to play with her child and that she was more open about her feelings
What improvements were secured for the parents / family
The mother begun to socialise with other mothers outside the meetings and attends play
facilities with other mothers. The mother has started to socialise again and has taken a part
time job.
Any numeric data – e.g. survey results
N/A
Further details
http://ihv.org.uk/news-and-views/voices/time-working-postnatal-depression/
Case study B
Development of a group to support mothers with identified mental ill health
Author Anwen Evans, Health Visitor, Southern Health NHS Trust
Date 10 August 2016
Perinatal mental illness is reported to affect 1 in 5 mothers in the United Kingdom and is
recognised as a major public health issue and the leading cause of death for mothers during
the perinatal period. The estimated financial cost is £8.1 billion and a significant proportion of
this relates to associated poor outcomes for children.
In Andover (Hampshire), based on the local birth figures, it is estimated that up to 16
mothers a month will encounter perinatal mental ill health following the birth of their baby.
Southern Health Foundation trust agreed to pilot a new group to support mothers with
identified mental ill health. ‘Knowing Me, Knowing You’ was developed in collaboration with
Andover MIND and the Specialist Perinatal Mental Health team in Winchester. The group
was facilitated by the wellbeing practitioner form MIND, the health visitor and a community
93
nursery nurse.
Colleagues who had previously facilitated ‘post-natal’ groups shared their knowledge and
experienced in running such groups and the Regional Specialist Perinatal Mental Health
team provided regular supervision.
Referrals were received from General Practitioners, health visitors and directly from mothers
who felt that they were experiencing symptoms of perinatal mental illness. An intensive
engagement approach to improve sign up was adopted. Each woman was sent a
handwritten card inviting her to the group to make her feel welcome.
Activities ranged from rhyme time to baby massage and fathers were incorporated into the
sessions in addition to a one off session to provide information, advice and support for living
with perinatal mental health difficulties.
It was recognised that, for some mothers, it can difficult to leave their baby when they feel
most vulnerable, so each session included an infant friendly activity to build mothers
confidence as parents and focus on responsive parenting techniques.
The group aimed to reduce symptoms, improve parental confidence and enable women to
develop social support networks.
The group discussed ways to understand when baby is feeling tense and anxious and
therefore restless. By supporting mothers to develop an understanding of their baby’s world
was found to be a key component of successful outcomes for children when mothers have
perinatal mental ill-health
Feedback resulted in a redesigned perinatal mental health leaflet, efforts to address stigma
and encourage parents to talk about how they are feeling to improve service provision
To capture women’s experience of perinatal mental illness and to ensure the professionals
heard their ‘voice’ group members were invited to participate in an innovative co-design
approach sing the Kings Fund Experience Based Co-design toolkit. This provided
information which has been used ensure services are more responsive to mothers needs
Showed how creating a new support group for mums with perinatal mental ill health led to a
follow on group by the mums themselves. ‘Knowing Us’ that will provide ongoing support to
women before and after the ‘Knowing Me, Knowing You’ programme
Further details
http://ihv.org.uk/news-and-views/voices/knowing-me-knowing-you
Case study C
Reducing harm to children from unintentional accidents (Homeless families)
Author
Trudi Law, Specialist Health Visitor (Homeless families) and Queens Nurse, The Royal
Wolverhampton NHS Trust
Date
29 September 2016
Families and expectant mothers who live in temporary accommodation often have been
subjected to domestic abuse and have usually moved in from outside the area. This could
mean that they have limited knowledge of locally available health services and sometimes
delay in registering with a GP or contacting a health visitor. Evidence suggests that
homeless families have a higher rate of accidents and hospital admissions. (Inequalities and
Deprivation, Making the Link, Child Accident Prevention Trust November 2013)
The limited space, communal living and unfamiliarity with the refuges and hostels pose
certain risks to the child.
As local audit examining the reasons for accident and emergency attendances demonstrated
that there was an opportunity to improve safety for families in temporary accommodation.
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The heath visitor therefore arranged a coordinated event during Child Safety week 2015
within the refuges, to increase parental and child awareness of accidental risk and promote
positive behaviour changes
During visits to the refuges the health visitor has opportunity to discuss potential risks and
educate parents. A specific tool for families in temporary accommodation has been
developed ‘Toddler Triangle’ based on the Choose Well Campaign.
The following services are now available and tailored to families living in temporary
accommodation;
 Home safety team
 Home safety equipment
 Fire safety scheme
 Home safety checklist in parent held record.
75% of parents living in temporary accommodation said that they had learned something
new and would make a positive change to improve home safety
The majority of families who move on from temporary accommodation said they felt better
informed about accident prevention. They have been equipped with the knowledge and skills
to keep safe, and are better informed about the appropriate use of local health services
Further details
http://ihv.org.uk/news-and-views/voices/reducing-harm-children-unintentional-accidents-
homeless-families/
Case study D
Reducing A&E attendance within Sutton and Merton community Services
Author
Debbie Holroyd
Date
25 April 2015
There is a national and worldwide trend of increasing attendances by children who are
seeking non urgent care.(What do we really know about infants who attend Accident and Emergency Departments
Hey, HM Kwong, J Reed and M Blair, Perspect Public Health, 2014 March 134(2) 93-100). The causes for the
increase in attendance are unclear and may be attributable to several factors including
increased parental demand, changes in work patterns within primary care, restricted access
to GPs and lack of awareness of other appropriate channels for help. (Children taken to
accident and emergency with routine complaints, Nursing Tines, 28 May 2011)
Sutton and Merton Community Services sought to address the issue to reduce inappropriate
attendance at the local A&E department firstly using CQUINN money to fund a full time
health visitor and nursery nurse.
A literature review revealed that pyrexia, diarrhoea and vomiting and respiratory issues were
the most common issues of concern bringing parents to A&E. The health visitor attended a
minor aliments 3 day workshop to up skill and following this a power point presentation was
developed to support the delivery of a programme designed to stimulate the awareness of
children’s health needs for parents when considering the best course of action for a child
who may be unwell. This was coupled with input into child accident prevention (based on
The Child Accident Prevention Trust model) also a major cause of A&E attendance.
The two staff lined with community pharmacists, children’s centres and child health clinics to
deliver minor ailment and accident prevention workshops which were well attended.
A health visitor duty line was set up in April 2013 operating from 9am to 5 pm where parents
can ring for advice and be signposted to other services if necessary or given direct advice by
the health visitor.
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From November 2014 to March 2015 non-recurring monies were used to fund ongoing work
in reducing inappropriate A&E attendances. This included a formal 90 minute minor ailment /
accident prevention workshop, a less formal shorter workshop delivered within existing
groups such a baby play and stay groups within Children’s Centres and voluntary groups,
brief interventions involving 5-10 minute discussions with individual parents / carer groups.
These included toddler groups and child health clinic waiting rooms and public health
promotion stands at school fairs and shopping centres.
Using questionnaire it was established that there was a marked increase in the parents
confidence in managing childhood illnesses, protecting them against accidents, knowledge
of the out of hour and minor ailment services and sources of relevant information
The health visitor duty line operating from 9am to 5 pm where parents can ring for advice
and be signposted to other services if necessary or given direct advice by the health visitor is
now part of the core service.
It is thought that the groups could be delivered and maintained within the health visiting
service and there is a waiting list of clients wishing to attend future workshops
The plan is to manage the demand using the RiO monthly team planner to receive referrals
Health visitors are well placed to help parents make the right choices with regards to their
child’s health and give parents the skills to manage some conditions safely at home whilst
giving them the knowledge to seek appropriate help, at A&E
By the end of the project 1054 families had been reached. Statistical analysis showed a
reduction in 1500 A&E attendances in the under 5s compared with the same period the
previous year. However a true causal relationship cannot be wholly inferred as this coincided
with other drivers such as introduction of the Health Visitor line and the work of community
pharmacies.
Further details
http://ihv.org.uk/news-and-views/voices/debbie-holroyd-on-reducing-ae-attendance-within-
sutton-and-merton-community-services/
Case study E
New Birth Visits and Infant Feeding
Author
Zoe Ralph, Healthy Child Programme Lead (Acting), Infant Feeding Health Visitor, Fellow of
the Institute of Health Visiting, Central Manchester University Hospitals NHS Foundation
Trust
Date
27 September 2016
Health visitors carry out New Birth Visits to all families with new-born babies as part of the
Health Visiting universal offer Health Visitors are uniquely equipped to support new parents
with the transition to parenthood and any feeding challenges that may occur. This ensures
every family receives timely and appropriate support.
A mum was a regular attender at the breastfeeding drop in, she was struggling breastfeeding
her now 9 week old baby. The baby was having difficulty latching on and mum had nipple
damage, this was affecting her physical. However she was determined to breast feed as
long as possible as the family had a history of severe diary allergy and was worried of
feeding her baby formula milk.
Mum had experienced a lot of problems during the first three weeks – the baby had tongue
tie which had gone undiagnosed for three weeks and poor latch and additionally mum had
experienced recurring thrush, blocked ducts ad horrendously painful vasospasms. By 13
weeks all the issues had been addressed
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Mum was supported though 5 drop on sessions, home visits and regular telephone calls
Due to the support of the health visiting team the mother was able to continue breastfeeding
and found the support and advice invaluable. Without this support mum advised that she
would have just given up on breast feeding.
‘I am so pleased to have been able to breastfeed my baby. She is now 9 months old and
we’re still going strong with feeding and she is showing no signs of stopping. I’m hoping to
continue to at least 1 year, possibly beyond and I honestly never thought I’d be able to say
that
‘I was devastated at the prospect of not being able to feed my baby the way I had hoped to,
and I can also say in retrospect it was really affecting me psychologically not being able to
feed my child as planned.
‘In my experience breastfeeding has been such a special bond between us, and nothing
makes me prouder than seeing my baby thriving, with her weight in the 95th percentile and
knowing I did that’
Further details
http://ihv.org.uk/news-and-views/voices/new-birth-visits-infant-feeding-case-study/
Case study F
Amelia Parents, Bristol Specialist Health Visitor for Teenage Parents, Bristol
Author
Barbara Hollis Clinical Team Leader Gosport Central Health Visiting Team
Date
March 2017
Amelia was the youngest of 3 siblings. She had two older brothers.
Amelia’s mum received an Ante natal contact prior to the birth.
Amelia was born at 3kg at full term with her weight on the 9th centile. Her length was on the
25th centile and her head circumference on the 50th centile.
Amelia was initially breast fed for the first 5-7 days and then went on to formula milk.
Amelia’s Mum, Lottie was a very busy caring full time mum. Amelia’s eldest brother Sam
has severe speech and communication delay and is on the Autistic Spectrum. He had
difficulties with extremely restrictive dietary intake, only eating custard creams, NICE
biscuits, and crisps in his lunch box. Lottie made sure that Amelia received each of the
Universal Healthy Child Programme contacts in the early postnatal period but she had little
opportunity to bring her to local child health advice clinics for routine growth measurements.
Amelia was seen opportunistically at home when she was 8 months old, as a community
nursery nurse visited to complete her brother’s 2 year health review. The Community
nursery nurse (CNN) did Amelia’s growth measurements and found that her weight had risen
to the 91st centile. The CNN gave some information about portion sizes and some healthy
weight advice and liaised with the Named health visitor to review her growth at her 1 year
health review.
By the 1 year Health Review which was done at home by the Named Health visitor, Amelia’s
measurements were as follows:
Weight: 11.69kg 8th-99.6 centile (born on 9th)
Length: 73.5cm 75th centile (born on 9th)
Head Circumference: 46.5cm 91st-98th centile (born on 75th)
The Ages and Stages Assessment indicated that Amelia’s gross motor development was
significantly delayed, as were her speech and communication skills.
Amelia’s gross motor development would have been being hindered by the fact that she was
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obese.
Amelia was referred to a CNN in the team to deliver the 1 to 1 HENRY programme.
The family were agreeable to this and engaged well with the programme.
Lottie found that her focus and anxieties around Sam’s extremely restrictive diet made it
difficult initially to take on the concepts around normal healthy family mealtimes.
With support from the CNN and persistence Lottie was able to gradually change the
behaviours in the family and ultimately change the pattern of the mealtimes and in turn of the
children’s nutritional intake.
The CNN also addressed other issues of general behaviour management advice and getting
rid of dummies and bottles for the children during the process of delivering the 8 week
programme in the home.
Prior to school entry the Health Visitor had referred Sam to the Dietician due to his extremely
restrictive diet and poor nutritionally. He was also heavy for his height.
The Dietetic advice was to not focus so much on the behavioural aspect of the eating and
not to evoke stress around food. This approach was very much endorsed by the HENRY
approach. The dietician advised re vitamin supplementation and milk intake, changing from
full fat to skimmed to ensure minimum levels were achieved for his nutritional status.
Mum’s quote, “found the HENRY 1 to 1 course really beneficial, it was easy to fit into family
life. Trying anything new is always hard in the beginning but by the end of it you don’t realise
you are doing it, it just became second nature. I would recommend that anybody give it a try
if it is offered to them!”
Amelia’s growth velocity has now slowed down significantly and she has reduced down on
the centiles and she is now a healthy weight.
Amelia is now walking and her gross motor development is now what you would expect for
her age.
Mealtimes are happier and less stressful in the household.
Her speech and communication development will be reviewed again at her routine 2 year
health review, although indications are that this is progressing.
Sam although was originally a very restrictive eater when recently seen by the school
nursing service he is now having foods from each of the food groups and drinking
appropriate fluids in appropriate volumes.
Further details
The mother has given her consent for this case study
Alison Morton is Professional Advisor for Health Visiting, Public Health England; Specialist
Practice Teacher, Southern Health NHS Foundation Trust, Hampshire
Case study G
Newcastle’s Hospitals Healthy Scheme returns to get children ‘school ready’
Author
Jacqui Smith, Health Visitor
Date
2016
The sessions encourage children to say Hello to the School Nursing team and Goodbye to
their Health Visitor. Hello/Goodbye brings together doctors, dentists, health visitors and
school nurses in the same place. This gives children the best possible chance to be
prepared for starting school by ensuring immunisations are up to date, and checks and
support on preparing for school such a language development and potty training
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Key sessions are addressed through interactive play including; oral health, healthy eating
and physical activity.
The sessions will cover everything from sleeping issues to potty training, tantrums to health
conditions; basically anything that could disrupt a child from having a smooth transition into
school life.
’Hello/Goodbye’ is essentially a way for us to provide a handover of services to parents, and
aims to ensure that children, young people and families have access and support with any
health needs, in line with the Department of Health’s Healthy Child Programme.”
It also gives our School Nurses a chance to carry out health assessments and identify any
children that may need additional support with health and wellbeing needs. Without this
scheme this would be a missed opportunity.
“For example, they can catch up on overdue immunisations, monitor height and weight and
review of dental health. It also gives the children a chance to socialise with other children of
the same age.”
The Hello/ Goodbye initiative was extremely popular in its opening year, with one clinic
managing to see 131 children in around four hours, excluding siblings
Further details
http://www.newcastle-hospitals.org.uk/services/NHCH_services_health-visiting-and-school-
health_supporting-children-starting-school.aspx
Case study H
Nottinghamshire Language for Life
Author
Joanne Young
Date
2014
In Nottinghamshire health visitors are working in partnership to identify and refer children
aged 2 years and under who are in need of support with speech, language and
communication. Research shows that up to 10% of children have a long term, persistent
communication disability and approximately 50%in socially disadvantaged areas have a
significant delay on entry to school
Children are identified by health visitors for referral to the Home Talk service by local health
visiting teams. The health visiting service completes this check between 2 -2.5 years. The
Home Talk service consists of six home visits. The aim being to improve language skills and
to provide early identification of children with complex speech, language and communication
skills.
This scheme was initially piloted in Mansfield but is rolled out across the county and
commissioned as part of the health visiting service. Benefits include supporting school
readiness at the age of five, therefore increasing educational attainment and thereby
reducing the health inequalities gap.
The increase in referrals to the home talk service has reduced the referrals to speech and
language therapists at a later stage. Health visiting teams have also benefitted by
developing their own knowledge and are better able to signpost and identify early help
Further details
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hv_case_study_broc
hure.pdf
Case study I
Behaviour Assessment Scale (NBAS) assessment of a very unsettled baby
Author
Sharon Swift, Health Visitor, Bridgewater Community Healthcare Foundation Trust
Date
28 September 2016
A 5 week old baby living with a foster parent was really unsettled and the initial health visitor
had exhausted all possible causes so baby was referred the baby to another health visitor
for a Neonatal Behaviour Assessment Scale assessment
On examination the baby was awake so the habituation assessment could not be
undertaken. The health visitor attempted to complete the assessment but the baby would not
comply. On observation the baby was unable to console himself due to intermittent startles
that seemed to be caused by pain. Being held in the ‘Tiger in the tree hold’ seemed to help
but after 10 minutes he became unsettled again. He would settle when rocked but this was
not maintained when still. His soother did seem to offer some relief.
The baby was prescribed an antacid and the following day there appeared some
improvement.
The health visitor also suggested some background noise as the house was quiet and baby
would have been used to noise in the hospital in the first week of life. It was noted that when
asleep he was only in a light sleep as he continued to move and murmur
The health visitor taught the foster mum consolably techniques including using a muslin cloth
around his middle to help hold his arms still and help settle him.
Subsequently the infant was referred by the health visitor and seen by a paediatrician and
diagnosed a milk intolerance.
Different milk was introduced with a positive effect and the baby settled and was no longer
distressed.
Use of the NABS assessment gave an insight into how the baby was feeling and evidence
that he could not settle. The health visitor input led to early identification of the issue,
signposting to specialist help and support for the foster mum.
‘I cannot believe it, he settled for a further 50 minutes when you left. He woke up crying but
soon settled when I tried some of the techniques you had shown me’
This meant the foster parents could establish a routine and baby was comfortable
Further details
http://ihv.org.uk/news-and-views/voices/nbas-assessment-unsettled-baby/
Case study J
Specialist Health Visitor for teenage parents in Bristol Parents, Bristol
Author
Rosie Dimond. Specialist Health Visitor, Bristol
Date
June 2014
Good progress has been made in reducing the under-18 conception rate in Bristol, but less
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support had been available to support teenage parents and their children, and address
Inequalities in health outcomes. A developmental post (3 days a week for 2.5 years) was
commissioned in 2012 to help improve young parent’s experience of and access to the
health visiting service in Bristol, with the aim of improving health outcomes for teenage
Parents and their children.
The post was established to improve experience for teenage parents as there was a real
inequity in the level of service received. Those parents who attended reported they did not
have a trusting relationship with their health visitor but often had multiple health
needs. The role has developed over time with a focus on three areas:
 Direct service delivery to teenage parents and their children
Regular clinics at school, in liaison with the family health visitor; drop-ins at supported young
parents housing projects and young parent groups aiming to build up trust and signpost to
health visitor services and other support; and involvement in educational outreach and multi-
agency antenatal groups.
 Service development
Identifying gaps in service and training needs for health visitor teams. Supporting health
visitors as a specialist resource. Participation surveys of teenage mothers’ views on health
visiting, and health visitors’ views on working with teenage parents. Identified training needs
led to updates on contraception and sexual health. Funding also provided in response to
the survey outcomes for creative training on communication and engagement with teenage
parents.
 Multi-agency working
Providing a direct link to health visitors and wide range of agencies. This post has allowed
time to work with and engage with other agencies supporting young parents, and raise
awareness of the role of health visiting. Feedback from agencies has been extremely
positive with an appreciation of the specialist health role a health visitor can provide.
Clinics are held during the term time (40 weeks), with encouragement given to attend
community clinics or see their family health visitor during school holidays. Young parents
have told the Health visitor for Teenage Pregnancy that they find it helpful being able to
weigh their baby and access health visiting advice at the specialist school which is focused
on providing education, support, mentoring and advice to teenage girls and young mothers
as they find it difficult to access community clinics as they are at school during working
hours.
Further details
Community
practitioner article.pdf
Case study K
Promoting Smoking cessation in pregnancy B
Author
Julia Robson (Quit 4 Life Lead) and Alison Morton (Head of Nursing)
Date
February 2017
A 19 year old pregnant woman was identified as a heavy smoker by the Specialist
Community Public Health Nursing team during at the antenatal contact. The women
identified herself as a single parent who had a medical history of asthma and depression.
Following a discussion about smoking and the benefits of quitting, the woman agreed to a
referral to Quit 4 Life as part of a priority local agreement for pregnant women. She attended
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the local quit smoking session at her GP practice and successfully quit smoking in August
2016. Her baby was born at term and there were no health concerns at birth. The baby did
not require any additional neonatal support and was successfully breastfed. The baby
continues to thrive and is supported by the Specialist Community Public Health nursing
team.
The mother continues to experience difficulties with her mental health, but remains a non-
smoker in February 2017.
Long term benefits of being a non- smoker and living in a non-smoking household for parent
and child
Further details
alison.morton2@nhs.net
Case study L
Author
Dionne Frazer- Specialist Health visitor for Asylum Seekers, Refugees and Migrants/
Traveling Families. Walsall NHS Trust
Date
February 2017
Walsall is one of the areas in the West Midlands into which asylum seekers are placed whilst
waiting for asylum claims to be processed. A Walsall’s Specialist Health Visiting (SHV)
Service for Asylum Seekers, Refugees, Migrants, Travellers and No Recourse to Public
Funds families has been developed. The needs of families using the Specialist Health
Visiting Service are diverse and complex. They often relate to experiences such as
persecution, trafficking, sexual abuse, domestic violence, mental health issues, sexual
exploitation, domestic slavery and female genital mutilation (FGM).
The SHV service provided to antenatal women and families with children 0 -5 in this client
group is supported by a robust system which includes:
• An initial home visit after arriving in Walsall, which includes offering skills support and
English for Speakers of Other Languages provision
• Tailored initial health assessments for asylum seekers which looks at the past medical
history of a child and a holistic health assessments which is inserted into the child’s personal
red book (each women and child is assessed and a care plan is formulated for each
identified need)
• Support to register with GP and dental services, local Sure Start children’s centre
provision, schools, sexual health services and other services
• An integrated multi-agency health approach
• Responding to safeguarding concerns
. A robust interpreting service
The SHV also trains local health and social care professionals to improve access to and
uptake of appropriate services for migrant families.
Training has been rolled out to Midwives, Health Visitors, Nursey Nurses, Support
workers and Sure Start staff.
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The service strengthens partnership working between agencies, hosting monthly meetings
that include the police; fire service; LA Equality, Afghan Community, Dementia Support
services, Safety and Wellbeing services; LA Crisis Support Team; Housing Group; Victim
Support; Citizens Advice Bureau; local charities, Library Services, Victim Support, Street
Teams- work with girls/boys –to support victims, raise awareness regarding sexual
exploitation, FGM survivors, G4s(Border Agency) -Housing provider for Asylum Seekers
and other relevant services.
The SHV receives referrals from housing services in which families newly dispersed to the
area are accommodated whilst awaiting the outcomes of asylum applications; and a local
hotel which is a house of multi occupancy where families live whilst awaiting rehousing,
attempting to regularise their immigration status (e.g. after overstaying visas), or appearing
against refusals of asylum claims. The service also accepts referrals from outside the
borough, and from families themselves.
Between January and April 2016, Walsall has accommodated 298 service users. Sixty-three
families have required Universal Plus or Universal Partnership Plus Specialist health visiting
service provision. Once these families have been given leave to remain they will follow a
universal pathway.
Feedback indicates that clients are happy with the SHV service, scoring it 10/10 in a
questionnaire. Most respondents stated that the service helped them with behaviour, diet,
education, GP appointments, referrals to other services, breast feeding and GP registration;
and communicated on their behalf with social services, teachers and the Home Office.
Further details:
https://www.basw.co.uk/resource/?id=5330
Case study M
Implementation of a text messaging service for parents to ask health visitors about their
child’s health
Author
Jimmy Endicott, Leicester City, Leicestershire and Rutland NHS Trust
Date
January 2017
Improved access to advice and guidance from health visitors was required to support
parents, particularly those of travelling families and families who are in contact with the early
start service. Local evaluation also showed that parents wanted to contact the service in
.different ways using a range of digital platforms
ChatHealth a safe and secure text messaging service has been introduced across the health
visiting service in Leicester, Leicestershire and Rutland making it easy for parents to ask
questions about their child’s health, wellbeing and development.
This service was launched in October 2016 in six areas of Leicester City, Leicestershire and
Rutland. It is also targeting two specialist services, traveling families and families who are in
contact with the early start service.
The advice and guidance given by text is evidence based and if there is need to see a health
visitor the parents are signposted to the relevant team. Health visitors work in partnership
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with colleagues in school nursing and pass over any enquiries from the parents of school
age children
Chathealth users receive an immediate automated response to let them know service
provision and emergency contact details if required. They are guaranteed a personal
response from a member of the team within 24 hours Monday to Friday 9am to 5pm. The
service is run on a rota basis .which means staffs take it in turns to respond to the messages
as part of their working day.
Uptake in the pilot doubled month on month during the first three months with health visitors
receiving around 300 messages so far. 71% of enquiries were about infant feeding and
general health, with the rest being about immunisations and sleep or requests to see a
health visitor. Where messaging has been used in other children and young peoples’
services it had proven to be an efficient way for small numbers of staff to handle many
enquiries quickly and safely and time has been released from the staff who are providing
face to face care so that more face to face contact can be allocated where it is most
needed. Messaging can be generally more discreet or timely for service users and staff
report speaking to more vulnerable service users who might be less likely to attend a face to
face drop-in or clinic.
All service users were asked for feedback at the end of the episode of care. 90%
respondents scored the service 5/5. 10% scored 4/5 or 3/5.
‘I feel like I got the answer to the question I needed and that there was genuine care for me
too. Questions were asked to make sure I was asking for the right kind of help and it didn't
feel too intrusive but like I could tell you things if I needed to’.
‘I wanted to action things from tonight & it's often longer to get a call back from h/v team so
love this new service. Thanks for the support & look forward to follow up & hopefully good
progress.’
‘Very swift response offering peace of mind. It's great to be able to text when you're not quite
sure about something but don't think it warrants going to the hospital or the doctor.’
‘It's so nice to have a contact that you don't feel your 'pestering' as many questions probably
go missed as mums feel they don't know whether to ask the midwife or health visitor
whereas I know I feel less of a 'pain' asking via this service’.
Further details
Jimmy.endicott@leicspart.nhs.uk
Case study N
Health visitor 6-8 week review ( Heal Bristol
Author
Anwen Naylor - Evans
Date
February 2017
Early identification of perinatal mental health problem, reduction of Edinburgh Postnatal
Depression Score (EPDS score), increase parental confidence , community support
A 27 year old woman was pregnant with her first child when she met her health visitor at the
antenatal contact. The antenatal assessment did not highlight any vulnerabilities or risk
factors; this was a planned pregnancy, there was no history of physical or mental health
problems, she had a supportive relationship with her partner and they were both working as
professionals. The health visitor noted that the couple had recently moved to the area with
no established support network.
At the birth visit the woman disclosed a traumatic birth experience, coupled with difficulties
with breastfeeding. The universal health visiting service enabled early identification,
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assessment and effective treatment of perinatal mental illness.

The mother received continuity of health visitor at her antenatal contact, new birth visit and
6-8 week postnatal review; this enabled an effective health visitor- client relationship. During
the 6-8 week review the woman presented as tearful and stated she had ‘failed at being a
mother from the outset, due to not being able to give birth as she had planned’. The woman
also described how she felt she had failed at breastfeeding and had resorted to bottle
feeding following advice from her GP, due to her baby’s weight loss.
The health visitor encouraged the woman to talk about her experiences and feelings and
also invited her to complete an Edinburgh Postnatal Depression Scale (EPDS) screening
tool which identified she was experiencing moderate symptoms of perinatal illness. The
woman described how she would have intrusive negative thoughts and her mind was
dominated by the belief that her inability to breastfeed meant her baby would not have the
best start in life. She also completed a Karitane Parenting Confidence Scale (KPCS) which
highlighted low parental confidence in being able to read her baby’s cues and recognise
what she needed.
The health visitor worked in partnership with the GP to plan the most appropriate care;
however the woman was reluctant to accept medication, but agreed to a series of 4 listening
visits. These visits allowed the woman to talk openly about how she was feeling and to
identify strategies to improve her emotional wellbeing and coping skills. She also identified
that she was feeling very isolated and lonely despite living on a large estate with access to
local groups, she felt that other people would judge her for her ‘failings as a mother’.
She was also invited to attend a health visitor led therapeutic group for women with perinatal
mental health difficulties. The group aimed to improve mental wellbeing, parental confidence
and to support parents to develop attuned relationships with their babies, it also provided a
forum for women to meet and develop social support networks to address social isolation
and loneliness that are often associated with perinatal mental illness.
By identifying this woman’s issue at the 6-8 week review the health visitor was able to
ensure early assessment of maternal mental health and access to appropriate treatment to
support recovery. The social support provided by the intervention group played a crucial role
in addressing social isolation and loneliness, with improved emotional wellbeing.
Quantitative outcome measures demonstrated that following health visitor led interventions
her EPDS has decreased from moderate severity of perinatal symptoms to a level which was
within normal limits. Her Karitane Parenting Confidence Scale score significantly increased
which demonstrated greater parental confidence and attunement towards her baby,
including a better understanding of her needs.
Mum says “This group helped me realise that I’m not the only person who feels like that and
I’m not failing… I can talk to people, I can learn that my anxiety can be managed and that it
won’t feel like this forever”
Whilst attending the group she was able to speak to her GP about accessing medication to
support her recovery. Following the 4 listening visits and 7 week group intervention she had
made a significant improvement in her parenting confidence. She was also able to
acknowledge that she had not ‘failed’, but had given her baby ‘the best start’ by responding
to her needs and developing an attuned relationship with her.
One year on and she is now part of a peer support network supporting other women in the
area with perinatal mental health problems which is managed by MIND.
Further details
anwen.evans@southernhealth.nhs.uk
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Case study O
Developing and delivering polish clinics in North Fenland
Author
Emma Morley, Cambridgeshire Community Services
Date
2012
Local data provided evidence that a large percentage of Polish families residing in North
Fenland were not engaging with the service particularly the 2 – 2.5 developmental checks.
Feedback suggested that effective translation support was a real barrier for engagement and
the existing model for delivering this was not flexible in meeting the needs of this specific
population, therefore not recognising or supporting some of the cultural differences within the
community.
The increased numbers of health visitors enabled the delivery of a joint project with the
Children Centres. The project involved providing specific Polish clinics that would encourage
peer support and build resilience in the community as well as assisting the service as well
as obtaining a greater understanding of the population needs to assist in further service
improvements Funding for translation devices was obtained. These devices were used to
help staff to provide an instant translation service, reducing the reliance on the on and the
cost of local translation services
Reported improved motivation and moral within the North Fenland Team
All staff actively involved with sharing the learning form the pilot
Effective partnership working established throughout the development
A greater understanding of the specific population needs through improved assessment and
core effective preventative work
A sharing of information and skills across the organisation has benefitted both practitioners
and families
The Polish community are actively engaged with the services available
Further details
hv_case_study_broc
hure.pdf
Case study P
A health promotion project to reduce unintentional injuries in and around the home
Author
Maggie Crosbie, Health Visitor, Barts Health NHS Trust, Stephen Abbott Honorary Senior
Research Fellow, School of Health Sciences, University of London
Date
November 2016
Unintentional injuries in and around the home represent an important health issue for
children under the age of 5. An average of 62 children under the age of 5 die from such
injuries every year between 2008 and 2012, and they estimate 40,000 children of this age
are admitted to hospital as an emergency admission each year for the same reason. This
health promotion initiative was led by a health visitor in a deprived inner London community
to reduce unintentional injuries in and around the home.
Three two hour sessions were held in a children’s centre. Children centre staff invited
106
parents to attend and in particular those parents who had previously been to A&E.
Bangladeshi heritage attended and sessions were co-facilitated by a Sylheti-speaking
nursery nurse.
Photography and participation theatre techniques were used to raise potential awareness of
risks to children in the home, and to engage those attending in discussion and problem
solving. The photographs the mothers took of potential hazards to their children around the
home in between the sessions which were later displayed in the Children’s Centres to share
the learning with other families who did not part of the sessions
The health visitor was able to identify that some mothers did not understand the stage of
development for their children and therefore were not able to recognise the dangers / risks
that could cause accidents or harm. This enabled the health visitor stress the importance of
accident prevention.
The health visitor also recognised that these mothers tended to be socially isolated and were
benefitting from coming together in the session to talk and offer peer support.
During these sessions the health visitor ensured that the atmosphere was welcoming and
comfortable and this provided an opportunity for the mothers to raise other health concerns
and questions which the health visitor was able to address.
Some positive behaviour changes were reported (Two mothers said they now waited until
their children were in bed before doing the ironing, others reported feeling more able to
challenge their families about home safety)
Mothers were willing to participate and expressed enthusiasm about the project. They
reported a raised awareness of dangers to children in the home, and a greater
understanding of the limits to children’s own abilities to assess risk realistically. Mothers
were also enthusiastic about the opportunity to meet one another and to discuss more
general issues of health, including their own
The mothers felt that the programme should be available to everyone or even made
compulsory, because of the high number of unintentional injuries. They said that they would
have liked a visit from the fire brigade, as none of them had fire alarms in their homes.
Further details
unintentional.pdf
Case study Q
Meals on Heels
Author
Leicestershire NHS Partnership
Date
2016
How you decide to feed your baby is an important decision. This web presence and app
which can be downloaded provides information about both breastfeeding and bottle feeding.
There is also lots of useful information about what support is available nationally and locally.
You can download the meals on heels app to your iPhone - a personal guide to local
support, local breastfeeding friendly venues, and a handy reference guide. On
breastfeeding there is information on the advantages, how it works, is my baby
getting enough milk? Expressing, breastfeeding out and about, breastfeeding and
returning to work, in pregnancy preparing for breastfeeding, top tips, local support
groups, starting solid foods, national and local support and resources. And other
useful information. There is also frequently asked questions for formula feeding
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This web presence and app which can be downloaded provides information about both
breastfeeding and bottle feeding. There is also lots of useful information about what support
is available nationally and locally.
Further details
mealsonheels app
108
Appendix 7: The voices of health visiting service

users
An overview of the findings from facilitated discussion groups with
parents and carers January and February 2017.
109
Visual representation of the themes described by parents and carers aligned to the six early years high impact areas.
110
The purpose of this document is to report on direct feedback gathered from Health Visiting
service users to as part of the benefits realisation review. A literature review was completed to
inform the development of a user questionnaire tool to support the facilitated discussions; the
tool was designed so it could be completed independently, in pairs or groups as part of a
facilitated discussion. This report draws together the key findings from direct consultant and
engagement with parents of children under 5 throughout January and February 2017.
The views of 531 parents were captured. 207 forms were completed. The remaining views were
captured within facilitated discussion. Parents from across England took part in the engagement
exercise including Cumbria, Lancashire, Greater Manchester, Merseyside, Surrey, Hampshire,
Cheshire, Lincolnshire, Kent, Warwickshire, Somerset, Sussex and West Midlands. Parents
across all socio-economic classes and ethnic backgrounds were involved. The sample size is
too small to map responses to ethnicity or background; however, the emerging themes were
consistent regardless of population.
Parents in a variety of settings were included, deliberately sampling business as usual; including
HV child health drop-in, postnatal illness support groups, domestic abuse survivor groups,
aquanatal, aqua-mummies, soft play areas, swimming lessons, coffee and chat groups, bumps
and babies groups, children’s centres activity groups,
Key themes and messages emerging from parents.
We value the Health Visiting service and would use it more if we knew:
 Health visitors are specialist registered nurses.
 Health visitors can prescribe.
 we can contact Health Visitor when we came home from work.
 we can ask for extra help.
We really value the 2 year development review,
We get lots of messages about healthy eating but invite us to it and make sure we can attend
.from many sources, information from Health
Visitors is useful but only as an addition to
. Change for Life and other sources
We would like;
 to meet our Health Visitor before the baby is born and especially want more access to
parent education. We want to feel more confident caring for our babies.
 help to meet and share tips and experiences with other parents. We want to feel less
isolated with young children. We want support from other parents in similar
circumstances to us.
 help us get the right support at the right time. Many of us experience low mood and
anxiety after baby is born We are still frightened that if we admit to low mood someone
will take our baby away.
 Support for breastfeeding. We understand breastfeeding is best, we don’t want to be
made to feel guilty if we can’t or choose not to breastfeed. Feeding support for
breastfeeding mothers is fantastic and helped us choose to breastfeed and kept us
feeding for longer.
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Meeting her when pregnant helpful

we got off on the right foot
Supportive and knowledgeable
Need more visits especially in first

year
Around half of us had an antenatal visit from a Health Visitor and we wondered how families
were selected for a visit. We didn’t know if everyone should have a visit or just first time mums or
maybe families that needed extra help.
We really liked our antenatal visits. We want more of them. We need more parent education, not
about childbirth itself but about baby care, feeding, sleeping, preventing “cot death”, bathing and
handling our babies. If we had more education we would have been less anxious once baby
arrived. We know Health Visitors are busy, so the parent education could come from someone
recommended by them.
Meeting the Health Visitor before birth helped us ask her questions when she visited our babies.
We need more visits in the early weeks.
My partner and I both needed much more preparation
Meeting her on scbu was
extra support before we had our son would have made
fantastic
a massive difference to enjoying the first months.
I had excellent pregnancy care from the team was I had an antenatal visit from a Health Visitor,
always available and gave great advice which my partner my 2 friends didn’t, I was worried what was
and I greatly appreciated. I wouldn't have been able to wrong with me that she needed to visit me
breastfeed if I hadn't had the further support. I was
surprised how much support I would need, so incredibly
grateful I had time to think about things when I was
off on maternity leave but once the baby was
born I was so tired I couldn’t think at all! More
. This service is absolutely vital, as a first time parent there is training from a Health Visitor then would have
so much on offer and the team have been incredibly been fantastic, when I had time and energy to
supportive. The team are so highly thought of throughout listen
the local community. Their level of expertise and support is
unmatched. A credit to the NHS!
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I wouldn’t be alive today without my HV
Approachable, friendly and non-judgemental
We all experienced some degree of anxiety when we had our first babies. For many of us
anxiety persisted and became a problem. About a third of us had low mood and feelings of
worthlessness and hopelessness within the first year of our babies lives. Only about 10% of us
told anyone outside our family how we were feeling.
We feel the stigma of post-natal depression still exists. Nearly half of us had worried at some
point that if we admitted to feeling so low our baby would be taken off us. About 20% of us felt
we couldn’t tell a professional no matter how bad it got.
If we had known our Health Visitor was a specialist nurse we would have been much more likely
to trust her enough to tell her about our mood.
When we did tell our Health Visitor the response we got was fantastic. We got the right help. We
weren’t judged, we were supported. Some of us say that we might not even be alive today if it
wasn’t for our Health Visitor.
The moment I picked up the phone and asked for help [health visitor] came over and I can't stress how amazing the support was.
I remember how gentle they were, it sounds silly but I was feeling so fragile I thought everyone would judge me and was scared.
My HV was my primary point of call and she was so understanding. Encouraged me to join a group, came to see me every week
for listening sessions and made me feel less alone. I couldn't have done this without my HV support, she was there through the
whole process, from my initial realisation, to coaching me through treatment options, helping me accept and supporting my
decisions. I cannot stress how important [HV] has been, she has been a rock and I credit her with my recovery so far
When I finally called the health visitor- it took me 3 attempts to My health visitor was amazing. She was supportive
actually go through with the phone call and once I spoke to them, without being patronising. She helped me through
they came over that same day- and I felt so much better having my some dark days. Nothing was too much trouble.
feelings validated. The health visitor put me at ease, listened and She made me feel that PND wasn't something that
was empathetic. They did not judge, just listened. As soon as I spoke was a taboo subject and that I could deal with it.
to the HV I relaxed and everything (all thoughts, feelings and She helped me understand PND and how I can deal
emotions) overflowed. I have felt very supported by [HV] with it
. during my journey
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Breastfed much longer than expected

due to good advice
Needed extra support – got loads
Relaxed and never rushed
Breastfeeding mums:
We felt supported, well informed and had great support and advice. We had lots of information
and guidance. We felt that we had fed for as long as we intended or even longer. Breastfeeding
support from our Health Visitor helped us surpass our own goals and we still feel proud of that.
We had great help when things went off the rails. We had prompt identification of tongue-tie and
got the right treatment in good time. We were supported to feed through mastitis.
Bottle feeding mums:
We know breastfeeding is best but if we chose not to or found it too hard we did sometimes feel
judged and were made to feel guilty. About a quarter of us felt that there was plenty help for
breastfeeding but very little to help us bottle feed our babies safely.
She [HV] spotted tongue-tie and it was fixed same Made me feel guilty about baby’s
afternoon, her latch was much better after that and weight
we were away
Confidence boosting I couldn’t breastfeed but didn’t like being a

second class citizen because of that
I had mastitis and would have given up but my HV

supported me and got me the right treatment and
The breastfeeding support groups and
reassured me to carry on feeding and my milk wasn’t
classes were fantastic, we are all still
poison; I carried on for 4 months after that
friends
So proud of myself – fed for 10 months 114

and no dummy!
Always available with advice

and support
No advice for vegan babies
Horrified when told how

much sugar was in baby juice
Most of us felt well informed about healthy weight and nutrition but the Health Visiting service
was only a small part of our information sources. We had seen and heard the Change for Life
messages. We all knew everyone should reduce sugar intake. We all knew that sugary drinks
were not good for babies and for teeth.
About a third of us had discussed healthy foods, drinks and weight with our Health Visitor. Over
half of us had discussed weaning with our Health Visitor. All of us had got messages about
healthy foods elsewhere; from different authors, blogs and websites; from TV adverts; from
dentists; from other parents and family members.
About 10% of us felt that weaning and nutrition advice was not tailored to our babies’ needs, size
and age. About 15% of us felt that weaning and nutrition advice did not take account of our
family or cultural food choices.
My baby was really hungry but couldn’t get advice Step by step support
.
about weaning at 4 months just told to keep going until
6 months – we were all upset, so I gave him some baby .
rice anyway, and didn’t go back to clinic again
.
Text book advice not tailored
or individualised to me and .
my baby
felt that I was listened to and
able to discuss issues that I All about baby led weaning
was struggling with. I felt very and I didn’t like that
supported
Children at all did
Centre staff times,
cook and eat
fantastic service.
course, that was great but didn’t talk
to HV about food I was on the phone all the
time – at every stage, always
got fantastic advice
Loads of information on the web didn’t ask HV
Helped me get Healthy Start

vouchers and vitamins
Had to talk about feeding to get HV to sign 115

Healthy Start forms, but she wasn’t sure Led by weight chart not
about which vitamins my baby needed tailored to my baby
when I stopped breastfeeding, didn’t feel
confident after that
Accident prevention
discussion was helpful
Great advice on all aspects

from my HV
I never knew the HV was a nurse! It

would make sense to talk to her about
illness but I though she just did baby
care
Only about 15% of us had consulted our Health Visitor about minor illnesses. About half of us
had received advice about safety from our health visitor, usually at around 1 year or the 2 year
check. Those of us that had received advice had discussed issues like car seats, garden ponds,
electrical sockets, stair gates, baby-proofing the home, hot drinks and hair straighteners.
Nearly all of us would see a GP for illness advice. About half of us would go to hospital A&E
even if we didn’t think it was an emergency as we were confident we would get seen. About a
quarter of us would use NHS direct or NHS choices.
About a quarter of us knew that our Health Visitor could give us advice, when we were chatting
we found out that our Health Visitor was a registered nurse; we are now much more likely to talk
to her about minor illness, we wish we had known sooner. About 10% of us knew our Health
Visitor could prescribe, knowing that would make us more likely to consult her about childhood
illnesses.
I think it’s a great idea that your health visitors can prescribe
Everyone and everything was helpful, calm, certain medications. It makes it much easier for mums and also .
reassuring. They gave me great advice over the eases doctors (GPs) workload. A fantastic resource that should be
phone. The home safety advice was something I used more and shouted about! I didn't know this was an option
hadn't considered. The health reviews were until today. Hopefully the eczema creams prescribed will help
fantastic
My HV didn’t know much about car seats we

went to Halfords instead
My HV told me she was qualified to prescribe
simple things but our local NHS won’t let her;
Doctors surgeries are hard to get into, my HV is more
that’s a real waste
available so if I knew she could help with illness I would
certainly have used her
Health visiting scheme could be powerful if
arranged better
Got told a lot about accidents when baby

My HV told me she was qualified to prescribe simple things was first born but nothing at 2 years when
but our local NHS won’t let her; that’s a real waste he was always hurting himself, timing
could be better
116
Fantastic service
More bothered with

paperwork than me
We like the 2 year check! We think it’s useful and the advice we get at the time is helpful.
About 10% of us think the 2 year check happened at nursery and we weren’t invited. About a
third of us couldn’t make the appointment we were offered because of work or older children at
school.
Supportive and
Only available to stay at home knowledgeable
mums not working parents
Made me realise I had strength
to make my own decisions
What else?
Those of us who had experienced domestic violence or had extra social needs felt the Health
Visiting service was a tremendous source of support and advice.
One of us was on the “care of the next infant scheme” after a sudden infant death, the Health
Visitor continued to visit each week for 6 months which was invaluable.
We don’t like answerphones and voice mail. Some services introduced a duty call line so we
always get answered by a real person; mostly we like that, but we still want to talk to our own
Health Visitor as soon as possible.
We need help to combat isolation and share our experience and tips with each other. We would
like it if our Health Visitor had an up to date list of coffee and chat groups, church hall
playgroups, support groups and soft play areas so we could meet up.
We want to see our own Health Visitor, we understand she can’t be everywhere so give us a
rota of clinics she is covering and we will make arrangements to get to her.
Don’t call us service users. Please call us parents, those of us who are carers or grandparents
think that parenting is a verb and we are all doing it so parents is an ok title, better than users,
which makes us think of drugs!
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In all honesty, I was dubious about

working with Health Visitors before
having my baby as I had heard a number
of 'horror stories' from friends, but HV
made such a positive difference for me
Future considerations regarding key themes:

 Trusted and respected:
The nursing profession is a trusted brand. Increased engagement will come from social
marketing and publicity giving a significant return on minimal investment. Ensuring that
families of very young children understand that the Health Visitor is a specialist nurse will
promote disclosure of mental health issues and encourage parents to seek advice about
minor illness. The trust placed in nurses may also promote early disclosure of domestic
abuse, safeguarding issues and parental lifestyle issues such as drug and alcohol use.
One of the most telling quotes from this study was in response to the question “thinking
about the overall health visiting service – what could have been better?” “Helpful if they
had a doctor or midwife working with them for health issue questions”.
 Using community based assets
The parents readily acknowledged that resources are finite; they suggest cost neutral
initiatives such as up to date lists of drop in groups to tackle isolation, promote community
resilience and shared repository of knowledge. Within finite resources, parents want to be
able to have the most access to their “own” Health Visitor and would like to know where
she is available at drop in for the next 2 months so they can plan to make the journey /
make the time to see her. They suggest powerful feedback will be available from footfall
rates.
 Adding value – capitalising on skills
Further consideration should be given to Health Visitors responding to minor illness,
prescribing from the community formulary and prescribing independently. Reducing the
pre-school child demand at GP surgeries and A&E is desirable and gives the Health
Visitor more contacts with the child and family for health improvement activity; however,
wider issues of “sickness service” and resource need to be ironed out. Being able to
118
support women with postnatal illness by independent or supplementary prescribing may

promote disclosure and reduce stigma.
Acknowledgements
We are very grateful to all the parents who gave us feedback and comment. We would also like
to thnk the following for their support, knowledge and co-ordination:
 Andrea Johns Professional Lead Health Visiting. Wirral Community NHS
Foundation Trust Cheshire East
 Alison Morton Head of Nursing and Allied Health Professionals - Children's Division
Southern Health NHS Foundation Trust
 Dr Nimarta Dharni, Senior Research Fellow, Better Start Bradford Innovation Hub, Born in
Bradford. Bradford Teaching Hospitals NHS Foundation Trust
Lena Abdu HV Team Leader, First Community Health and Care Surrey
 Trudy Mills Interim Director Business Development and Associate Director for Childrens
Services, First Community Health and Care Surrey
 Cindy Freeman Quality and Patient Safety Manager Wirral Community NHS
Foundation Trust
 Tess Hickson Health Visitor Practice Teacher, Children and Young People Public Health
Services, Canterbury and Coastal health visiting team Kent Community Health NHS Trust
 Catherine Churchill Pathway Lead- Stakeholder Engagement, Lincolnshire Community
Health Services, 0-19 Universal Services
 Andrea Fallon Director of Public Health and Wellbeing, Public Health Service, Rochdale
 Amanda Tombs Health Visiting Team Manager Sussex Community NHS Foundation
Trust
 Jan Reynolds Head of Service C & YP Universal and Targeted services, HMR
Community Services, Pennine Care NHS Foundation Trust
 One to One Midwifery (North West) Ltd
 Mandy Allonby Midwife Lead for Aquanatal University Hospitals of Morecambe Bay
 Anwen Naylor-Evans Health Visitor Children's Division Southern Health NHS Foundation
Trust
 Justine Rooke Health Visitor Scarborough Harrogate and District NHS Foundation Trust
 Anna Geyer New Possibilities
119
120
Appendix 8: Stakeholder special interest groups

National Network of Designated Healthcare Professionals for Safeguarding Children (NNDHP)
Review of mandation for Universal Health Visiting Services - 2016
The response of the National Network of Designated Professionals for Safeguarding Children (NNDHP)
Introduction:
The NNDHP membership comprises all NHS Designated Professionals (Doctors and Nurses) who work in the areas
of Child Safeguarding, Looked After Children (LAC) and Child Death Overview Panels (CDOP). The Network exists to
provide a national voice to Designated Professionals. Its objectives are:
 To influence national strategic objectives and policy
 To provide peer support
 To promote analysis and learning
 To develop review and research partnerships
 To establish a repository of expert material
Description of mandation:
Mandation for Universal Health Visiting Services allows for6
 Antenatal health promoting visit;
 The new baby review;
 6-8 week assessment (the health visitor or Family Nurse led check). The GP led 6-8 week check will
continue to be commissioned by NHS England;
 One year assessment; and
 2-2½ year review.
We note that the mandation is therefore for contact as opposed to specific activity.
NNDHP position:
We regard mandation as a vital strategic tool to facilitate
 the right of all children to access the best possible health7, and
 the right of all children to the improvement of their wellbeing8
 the recognition of need9
121
Rationale:
We have an obligation to place the needs of our children first and foremost. This principle of paramouncy was
established in legislation10, and is also written into statutory guidance11.
Government funding for local authorities (LA) has fallen in 28% in real terms over the 2010 spending review
period. This reduction will reach 37% by 2015-16 based on illustrative data from the Department.12 And although
the impact of this reduction in LA spending power is reported as varying “widely, with authorities that depend
more on government grants seeing bigger falls in spending power”, it is hard to be overly confident about the
prospects for children’s services when the same report states that “Local authorities have tried to protect
statutory services”.
In the face of this, and the reported increases in workload in child protection and Looked after Children services,
as well as significant increases in police reports of crimes against children13, it is our view that mandation must be
continued to ensure that professional wellbeing support continues at a stage in life when children are most
vulnerable. Mandation will make an increasing difference in an era of declining resources.
Various learning points in the Brandon report14 serve to emphasise the vulnerabilities of under fives. The same
report also highlights protective factors that would be afforded to all children as well as the wide variety of
acknowledged risks that can be hidden without mandated checks.
An extended purpose to Mandation

It is widely recognized by practitioners that families that are not obviously living in deprivation may escape
engagement and support. But on the grounds of equity, this is not sustainable. Mandation will continue to ensure
that this does not happen. That notwithstanding, it is important not to forget that the most vulnerable families are
less likely to be supported by other means because they are the families that are least likely to attend clinics and
group facilities. Contact with health visitors can also aid trust in primary care services that otherwise wont be in a
position to spot signs of the more chronic developmental problems that would benefit from early intervention.
So as well as the mandated contact, we would suggest that the development of effective positive relationships
(the golden thread of relationships as the Care Inquiry so elegantly phrased it15) between health visitors and their
families and children should be positively supported.
Specifically, observations with regard to the home safety, engagement of fathers, nursery and social absence,
social development, awareness of the risks of trafficking, slavery, domestic servitude and sexual exploitation could
be usefully added to an expanded mandate for Health Visitors. All these would be in addition to increased
awareness building around mental health issues and drug and alcohol dependency, poverty, and nutritional
difficulties.
It is understood that these issues are routinely spotted and reported by Health Visitors without it being mandated.
Our position is that these functions should be added to the mandation for the reasons outlined above.
Summary:
122
The NNDHP firmly believes in the benefits of a continued and expanded mandate for health visitors as part of a
coherent sustainable approach to promoting childhood wellbeing and access to the best possible health.
13th October 2016.
1. Mandating elements of the Healthy Child Programme through Regulations. Dept of Health March 2015
th
2. UNCRC Resolution 44/25 of 20 November 1989 Article 24
3. Children Act 2004 Sec
4. Not Seen, Not Heard; (p 5, Recommendation 3) Care Quality Commission report, May 2016
5. Children Act 1989, Sec 1
6. Working Together to Safeguard Children, para 12. HMG March 2015
7. Impact of Funding Reduction on Local Authorities. National Audit Office November 2014
8. How Safe are Our Children, Report NSPCC 2016
9. Brandon et al: Pathways to Harm, Pathways to Protection. DofE May 2016 pps35, 40, 65, 67, 70, 73, 74, 75, 77, 88,
90, 96, 97, 140, 145
10. Making, Not Breaking: The Care Inquiry 2013
123
I CAN
An open letter from Bob Reitemeier, I CAN Chief Executive, to the Chief Nurse at Public Health
England
Posted on: 08-19-2016 by:ICANCharity
The Department of Health has commissioned Public Health England (PHE) to carry out a review
into the future of health visitor family checks beyond March 2017. Options put forward to ministers
include renewing the mandatory requirement, amending the number of visits, or scrapping the
requirement altogether. I CAN’s Bob Reitemeier has written to PHE urging them to consider the
impact this will have on children with speech, language and communication difficulties.
Dear Viv Bennett,
Re: Children’s public health 0-5 years – review of mandatory health checks
We at I CAN, the children’s communication charity, know that in some areas of the country more
than 50% of children starting school have delayed language. That is a shocking number of
children without the skills they need to learn and to make friends, ultimately impacting on social
mobility and the wider economy.
We also know that age 2 to 3 (1001 first days of a child’s life) is a critical time for children and their
parents. It is a period of rapid growth, learning and development in a young child’s life and is also a
key time when a child’s need for additional support from health services or the education system
can become clear.
We write to you to express our great concerns regarding the options put forward to ministers
relating to the five health checks currently expected between the age of 0 and 2 and a
half. Suggested options include reviewing the mandatory nature of the requirement, amending the
number of visits, or scrapping the requirement altogether.
There is enormous risk attached to the removal of any of the above options. More children with
communication difficulties will go unidentified and fail to receive the support they need. They will
start school without the skills to access education, going on to fail exams, making it more difficult
for them to find work. Children with communication difficulties often end up on the edge of society
as adults and many require financial and mental health support from Government during their
adulthood. The importance of the integrated review was recognised by the Department for
Education in this report, the findings of which remain critically important today.
Health checks make a real difference to a child’s future outcomes. They enable good parenting
practices to be supported, including the achievement of typical communication development. The
checks bring together families, health visitors and practitioners and are key in identifying
communication difficulties early, so that effective early intervention can be offered for those
children who need more support, at an age when interventions are critical and effective.
We know from our evidence that when the correct support is put in place before a child is aged
5 and a half, children are very likely to catch up with typically developing children of the same age.
If the five health checks are scrapped, there is likely to be a significant impact on the support and
advice parents get for their child’s development and on early identification. This is particularly
important for the 32% of disadvantaged 2 year olds who are not attending early years
settings. They would not receive any formal language checks until they enter school.
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Without the five checks and more specifically the Integrated Review at age 2 and a half, the 50% of
children in some areas starting school without the language skills they need is extremely likely to
grow. Ultimately, this will increase the financial strain for Government and adult services as these
children grow older.
I urge you to consider the longer impact a reduction in these checks of any type will have on the
future of children and our economy.
Yours sincerely
Bob Reitemeier CBE

I CAN Chief Executive
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British Heart Foundation
Responding Feedback has been provided by three members of the British

organisation Heart Foundation National Centre for Physical Activity and Health
(BHFNC) Early Years Advisory Group:
 Liz Prosser
 Dr Lala Manners
 Natalie Matthewman
On behalf of
Approved by:
Main recommendation on mandation
 The Integrated Review is beset with problems – the initial concept was to get
health/education to work more closely together – for a variety of reasons this hasn’t
happened – not least because they have incompatible software systems – time
constraints/geography/language-literacy – all have had an impact. An IR now can be
considered a quick phone call to share information – the chances of all relevant
parties actually being together in the same room at the same time to assess the
same child are very slim indeed : Recommendation : Conduct a comprehensive
review of practice – what works/what doesn’t – and why. Then research the
possibility of up-skilling the EY workforce so they may conduct the components of the
health part of the IR that is most relevant to their practice/settings. We would also
recommend that the role of physical activity in child development is acknowledged
within the Integrated Review.
 There is no consensus as to what constitutes ‘school-readiness.’
Parents/practitioners/health professionals/physiotherapists/psychologists all have
very different views. It has become a vague ‘blanket’ term that seems to cover
everything and nothing – the EY workforce dislike the term and won’t use it – so no
one can establish what - or whom - children are getting ready for – or
why. Recommendation : Either by questionnaire or direct consultation with relevant
bodies – work out what ‘school-readiness’ is – agree on the terminology – and stick
to it.
Benefits of the Healthy Child Programme
How important are the universal reviews to delivering benefits associated with the 6 high
impact areas? Extremely, very, somewhat, not so, not at all
Comment on the perception of the relative importance of

 Transition to parenthood – very
 Maternal mental health – extremely
 Breastfeeding – extremely
 Healthy weight – extremely
 Managing minor illnesses & accident prevention – very
 Healthy 2 year olds and school readiness – extremely
Are some of these considered to be more or less important than others?
What are the reasons for this?
 Maternal mental health is considered to be a key factor in a child’s development,

health and wellbeing
 Breastfeeding is essential for maintaining a healthy weight; Healthy weight is key for
preventing and managing child and adult obesity and for chid development, health
and wellbeing;
 Health and wellbeing is essential for school readiness and for improving child life
chances.
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Does this help to form recommendations on mandation? Especially if there is a

recommendation for mandation to continue in a revised form.
Other reflections
Physical development plays a critical role in supporting children’s engagement and
enjoyment of curricular activities as they start school. Simple tasks eg. sitting still/holding a
pencil/washing hands/lining up are all dependent on well-developed physical skills that may
be rehearsed and refined on a daily basis. Screen time is of concern – this not only has a
negative impact on the essential skills required for literacy (hands/eyes) – but also on the
time afforded for children to experience the physical activities necessary for their overall
health/wellbeing and development.
The Health Survey for England (2012) has shown that 91% of children aged 2-4 years are
not meeting the Chief Medical Officers’ Physical Activity Guidelines, and 7% of children aged
2-4 are sedentary for 6 or more hours a day on week days. Health visitors are in a unique
position to discuss physical activity with parents and its impact on health and motor skill
development through the Healthy Child Programme.
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National Children’s Bureau
Main recommendation on mandation

What is your recommendation for the future of mandation? i.e. Expire, extend in current form, extend in a
revised form
Extend in current form from April 2017 with some small changes considered thereafter.
What are the principal reasons for this recommendation?
We support the Healthy Child Programme as an evidence based programme that ensures young
children’s needs and those of their parents are identified early, contributing to safeguarding and
tackling inequalities in health and other outcomes. We are not aware of any evidence that
suggests any particular aspect of the programme prescribed in current regulations is less important
than others.
We support innovation by local authorities to meet the needs of their local populations. NCB leads
the Lambeth Early Action Partnership – one of five sites across the country that are part of the ‘A
Better Start‘ initiative. A Better Start aims to improve the life chances of babies and very young
children by delivering a significant increase in the use of preventative approaches in pregnancy
and first three years of life. Health visitors are at the heart of local teams driving forward this work
and new offers are being built that extend out of the healthy child programme.
The great work that is being carried out as part of ‘A better start’ and other programmes has not
required relaxation in regulations. Furthermore, we believe it would be the wrong time to make
significant changes and that doing so could have serious unintended consequences. Local
authorities have only just started to get to grips with their new role in children and young people’s
public health. As will no doubt be echoed by other submissions to this review, many local
authorities will have inheritied contracts for the delivery of health visiting services when they first
took formal responsibility for public health of under 5s in October 2015. Many will therefore only
now be starting to think about how they may want to tailor their offer. Regulations will ensure that
all those involved in local decisions will take the responsibility for commissioning these services
seriously and encourage them to invest the requisite amount of resources to deliver a viable offer
to local parents and young children.
NCB has been collecting evidence on behalf of the All Party Parliamentary Group for children for
their inquiry in to children’s social care. Many local authorities and voluntary sector organisations
have submitted evidence stressing the importance of early intervention services but also that it is
hard to maintain investment in these relative to services for children with more acute needs.
Submissions attribute this in part to the fact that early intervention work is not subject to the same
level of regulation. Spending on safeguarding children and young people services (including
social work, child protection, commissioning, and Local Safeguarding Children’s Boards)
has reduced by 11 per cent between 2010-11 and 2015-16 and on services for looked
after children (including those in residential care, foster care, under special guardianship,
recently adopted, leaving care or seeking asylum) by 4 per cent over the same period. This
suggests not only that regulation can help to protect investment in key services locally, but also,
unfortunately, that vulnerable families will now be more reliant on health visiting services because
of other early intervention services receding.
Disinvestment is a real risk in the current climate as local authorities face funding pressures, not
just from ongoing reduction in the ring-fenced public health grant but also their core revenue
support grant. English local authorities overall spending power has decreased by around 20
percent since 2010-11. (House of Commons Library (2014) Local Government Finance
Settlement 2014/15). Without continued regulation the temptation for local authorities to
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disinvest in these services could be too great in some areas leaving a gap in support for families
that could mean long lasting damage for children whose needs are not identified and addressed as
a result
If the mandation were to continue in a revised from what changes would be proposed?
We believe that there is potentially some scope to improve the legislative framework for health
visiting services and the wider healthy child programme. New statutory guidance should be issued
to local authorities, clinical commissioning groups and NHS England setting out their respective
responsibilities for the continued delivery of the health child programme.
The current regulations require the provision of five universal health visitor reviews to all eligible
persons each including a development review ‘as set out in the Healthy Child Programme’ –
referencing Department of Health guidance from 2009. The referenced guidance was not originally
written as statutory guidance for local authorities and is described in its introduction as a ‘guide…
for primary care trusts (PCTs), local authorities, practice-based commissioners and providers of
services in pregnancy and the first years of life’ setting out ‘the recommended standard for the
delivery of the HCP and [demonstrating] how the programme addresses priorities for the health
and wellbeing of children.’
While we do not suggest that the suite of recommendations set out in 2009 are themselves out of
date, it could be made a lot clearer what local authorities legally ‘must’, ‘should’ and ‘could’ do to
deliver the programme. It could also be made much clearer what intervention, support and
discussions are expected to be part of the development reviews required by regulations and what
are recommendations for services to secured by local authorities and other commissioners.
Any new statutory guidance should take into account the latest available evidence, including that
submitted to this review of mandation as well as the Rapid review to update evidence for the
healthy child programme 0 to 5 published by Public Health England in 2015 and the ongoing
evaluation of the Family Nurse Partnership. The development of this guidance should also take
place in consultation with the wide range of services in the statutory and voluntary sectors who
support children and families in the early years, particularly those working with the most
vulnerable, as well as parents and children themselves. This process would of course take time
and may not be possible to complete in time for new regulations being lade ready for next year.
We would therefore suggest that this takes place over the next year to a8 months with regulations
being amended in 2018 or 2019.
Benefits of the Healthy Child Programme
How important are the universal reviews to delivering benefits associated with the 6 high impact areas?
Extremely, very, somewhat, not so, not at all
 Transition to parenthood
 Maternal mental health
 Breastfeeding
 Healthy weight
 Managing minor illnesses & accident prevention
 Healthy 2 year olds and school readiness
Are some of these considered to be more or less important than others?
Does this help to form recommendations on mandation? Especially if there is a recommendation for
mandation to continue in a revised form.
The six high impact areas are all very important and make a vital contribution to healthy childhood
and tackling health inequalities. We would also like to highlight the vital role that health visitors play
in identifying potential special educational needs and disabilities, including through the two and a
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half year review, allowing plans to be put in place to meet additional needs in early education and
school ahead of time.
How important are the universal reviews to delivering benefits/discharging responsibilities associated with
safeguarding and child protection? Extremely, very, somewhat, not so, not at all
 Safeguarding
 Child protection
Are these considered to be more or less important than other aspects of the Healthy Child Programme?
Does this help to form recommendations on mandation? Especially if there is a recommendation for
mandation to continue in a revised form.
Universal reviews are more important for safeguarding and child protection than they have ever
been. As highlighted above vulnerable families will now be more reliant on health visiting services
because of other early intervention services receding. Other front line universal services are also
under pressure, increasing the risk that vulnerabities and signs of neglect and abuse will be
missed.
- In accident and emergency units, for example, the percentage of patients admitted or
discharged within four ours has dropped from 98.% in 2009/10 to 91.9% in 2015/16 (NHS
England (2016) A&E Attendances and Emergency Admissions 2016-17: Quarterly time
series 2004-05 onwards with Annual (11.08.2016))
- While it is welcome that investment in General Practice is to increase, there has still been
no action to address the skills gap in working with children faced by many GPs as a result
of not having opportunities to work in child hospital settings as part of their initial training
(Children and Young People’s Health Outcomes Forum Report 2012 p54
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216852/CYP-
report.pdf;
NHS England (2016) Five year forward view for General Practice)
- Between 2010- 11 and 2015 - 16 the central government early intervention allocation to
local authorities has fallen by 55 per cent in real terms. Some of the biggest falls in local
spending have affected Sure Start children’s centres which have seen budgets reduced by
almost half (48 per cent) in real terms in the last five years. (Action for Children, the
National Children’s Bureau and The Children’s Society (2016) Losing in the Long Run:
Trends in Early Intervention Funding)
It is absolutely vital that there is some universal element to support for families in the early years,
and particularly shortly following birth. It will be hard to identify those families who may be facing
difficulties without home visits, particularly given the impact that the arrival of a child can have on
the lives of new parents. Furthermore creating a service that is only targeted based on risk could
create stigma in accessing such a serve and mistrust such as may be experienced by social work
professionals trying to offer a family support. This would create an increased risk of vulnerable
families slipping through the net, putting children at risk.
What is the perception of return on investment for these services? Positive, neutral, negative
There is a wealth of evidence for the return on investment that can be gained from early
intervention in children’s lives to support better outcomes. (See for a summary (2011) Early
Intervention: The Next Steps An Independent Report to Her Majesty’s Government Graham Allen
MP, p31) Health visiting not only represents vital work with children and families at an important
time of their lives but also allows the identification of families who have most to benefit from more
targeted and intensive early intervention programmes enabling referral and signposting.
Other reflections
Other comments
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Recommendations on next steps/further work required?
The Communication Trust
The Communication Trust

Public Health England Every child understood
West Offices
Station Rise 31 Angel Gate
York Goswell Road
Y01 6GA London
EC1V 2PT
Phone: 020 7843 2526

Fax: 0845 225 4072
Website: www.thecommunicationtrust.org.uk
03rd August 2016
Dear Viv Bennett and Phil Norrey
I am writing on behalf of The Communication Trust, a coalition of 53 not for profit organisations who
work together to support the children's workforce in ensuring that all children and young people are
enabled to develop and use their speech, language and communication skills to the best of their
ability.
I have read with interest the information regarding Public Health England's review of the five
mandated health visitor reviews and would like to take this opportunity to express some of the
coalition's concerns.
Currently, health visitor checks are provided as a universal service; a service that can benefit all
families. The universal aspect of these mandatory checks help to ensure that all children and families
receive the support they need at the earliest possible time and can prevent children with speech,
language and communication needs and SEND from slipping through the net and missing out on vital
early support.
Speech, language and communication skills are crucial life skills, and we believe that the support that
health visitors provide to families, in particular the 2-21/2 year check, provides an essential public
health service in promoting the importance of speech, language and communication skills to families
and supporting the early identification of children who may not be developing the skills expected for
their age. We know that early identification and intervention can make a huge difference to children
who are falling behind. Where difficulties are not identified and supported early, this can result in
children not being school ready and ultimately impacting on their literacy, learning, social relationships,
emotional development and employment prospects. Ofsted's recent report' looking at how Local
Authorities support disadvantaged families highlights in particular that local authorities should ensure that
131
a child's health and development checks at age two are completed as a crucial first assessment of their
needs, and used as a benchmark for progress across their early education.
Mandatory health visitor checks are an important public health service, and have the potential to ensure
that fewer children start school with speech, language and communication needs lower than expected
for their age (which in some areas, can be up to 50% of children). Additionally, in the context of the
DfE's Early Years Foundation Stage Profile becoming non-mandatory in September this year, it will
become even more important to ensure that frameworks are in place to support early identification
and intervention for children with speech, language and communication needs and wider SEND.
Considering the crucial role of the mandatory checks, we would be extremely concerned if that mandation was not
extended; these early checks and early support for children and families needs to be seen both as a public health
priority and as an investment priority for Local Authorities.
We would very much like the opportunity to meet to discuss these issues and further support that we could
provide — I can be contacted on oholland@thecommunicationtrust.org.uk
Yours sincerely,
Octavia Holland
Director, The Communication Trust
The Communication Trust is a collaborative Trust founded by Afasic, BT Better World Campaign, Council for Disabled Children and I CAN and supported by
government, private and voluntary sector organisations. The Trust is a restricted fund of I CAN registered charity no 210031
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UNICEF
Children's public health 0-5 years reviews
Survey deadline: 31 July 2016
Public Health England (PHE) is undertaking a review of the mandation for children's
public health 0-5 years (universal health visitor reviews).
Question 3: (page 4)
Mandation
Existing legislation, mandating that five universal health visitor reviews
(antenatal, new baby, 6-8 weeks, 1 year and 2-2½ years) are delivered for
every child, is due to expire at the end of March 2017. What would you
recommend happens next?*
The mandation is extended in its current form
The mandation is extended but in a revised form
The mandation is allowed to expire as planned
Don't know
Free text box - reasons:
The National Infant Feeding Network (NIFN) co-ordinates and supports health visitors across
England. The National Infant Feeding Network aims to improve the health and wellbeing of
mothers and infants by enabling excellent practice for infant feeding and relationship building
through public services including health visiting.
NIFN fully supports good practice by extending in its current form the mandated
health visitor visits. NICE evidence suggests that when women receive; one to one, face to
face, predictable support they are more likely to succeed in their breastfeeding choices which
will then have a positive impact of the mother baby relationship enhancing the physical and
emotional wellbeing of the baby, the mandated HV visits support implementation of this
evidence based practice. Where women have had a meaningful contact and conversation in
the antenatal period (around infant feeding and importance of connecting with their baby
during pregnancy and beyond) they demonstrate greater resilience postnatally and are more
likely to both initiate and sustain breastfeedingi.
Why this is important for public health and for mothers and babies:
 Breastfeeding increases the life chances for all children, reduces obesity and reduces
morbidity and mortality in preterm and sick infantsii,iii.
133
 The Lancet breastfeeding series, 2016, identified that the UK had some of the lowest
breastfeeding rates in the world - In the UK 81% of mother’s initiative breastfeeding at
birth, but by 6/8 weeks 76% of all babies have received some formula milkiv.
 Only 1% of UK women are exclusively breastfeeding to six months as recommended
by the WHO/Unicef and the UK Governments, and 34% partially breastfeeding
compared to 71% in Norway.
 Positive early mother baby relationships provide the basis for improved emotional
wellbeing throughout childhood and into adulthoodv
The mandated HV visits ensure women get predictable, face to face support to help them to
successfully breastfeed for longer and therefore address the very low breastfeeding rates in
the UK.
Question 5: Page 6 all are *extremely important
Final section
General comments: suggested text, page 7
Main Risks
 The United Nations Committee on the Rights of the Child (2016vi), the Chief Medical
Officer (CMO) (2013vii & 2014viii) and compelling evidence published in the Lancet,
2016ix, all identify that the UK has some of the lowest breastfeeding rates in the world
and calls on government to; systematically collect data on breastfeeding; promote,
protect and support breastfeeding in all policy areas where breastfeeding has an
impact on child health and fully implement the International Code of Marketing of
Breastmilk Substitutes.
 Without mandation there is a REAL risk that health visiting services will be cut and
breastfeeding and relationship building reduced to a level that would impact on
breastfeeding prevalence.
a. The health, wellbeing social and economic benefits of breastfeeding are
irrefutable; Breastfeeding increases the life chances for all children, reduces
obesity and reduces morbidity and mortality in preterm and sick infantsx,xi.
b. Reducing the incidence of just five illnesses, (ear, chest & gut infections, NEC
& breast cancer) protected by breastfeeding, would translate into cost savings
for the NHS of more than £48 million and tens of thousands fewer hospital
admissions and GP consultationsxii,xiii.
c. Breastfeeding can provide a child with a natural safety net against the worst
effects of poverty. Breastfeeding and supporting all mothers to build a close
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and loving relationship with their infant, is now recognised as a positive,
proactive mechanism to promote mother-infant bonding, reduce child neglect
and improve mental health and wellbeing for the mother and childxiv,xv,xvi,xvii.
 Data collection: since 2010 there has been no UK data reporting mechanism beyond
6/8 weeks. Health visitors are key to collecting infant feeding data and integral to
processes to ensure quality control and ensuring robust reporting mechanisms.
Without mandated visits there would be no breastfeeding data collection beyond
initiation.
a. The United Nations Committee on the Rights of the Child (2016) call for the
UK government to systematically collect data on breastfeeding; to promote,
protect and support breastfeeding in all policy areas where breastfeeding has
an impact on child health.
Opportunities for innovation
1. The CMO (2013), NICE (2010xviii,2014xix, 2015xx,2016xxi), Public Health England

(2015xxii) PHE and Unicef UK, (2016xxiii), the Acta Paediatrica Special issue and the
Lancet series (2015xxiv, 2016xxv) all recommend implementation of the Unicef UK
Baby Friendly Initiative as an evidence based programme that will help to improve
practical help for mothers to initiate and continue to breastfeed across community
services – mandating HV services will help to achieve this evidence based practice.
1
Unicef UK (2013) The evidence and rationale for the Unicef UK Baby Friendly Initiate standards
http://www.unicef.org.uk/Documents/Baby_Friendly/Research/baby_friendly_evidence_rationale.pdf .
1
Acta Paediatrica (2015) Special Issue: Impact of Breastfeeding on Maternal and Child Health, December,
Volume 104, Issue Supplement S467, Pages 1–134.
1
Renfrew MJ, Craig D, Dyson L, McCormick F, Rice S, King SE, Misso K, Stenhouse E, Williams AF (2009)
Breastfeeding promotion for infants in neonatal units: a systematic review and economic analysis, August,
Health Technology Association.13.No.40
1
McAndrew F, Thompson J, Fellows L, Large A, Speed M, Renfrew MJ (2012) Infant Feeding Survey 2010,
Health and Social Care Information Centre, pp. 111–112
1
PHE (2015) Rapid Review to Update Evidence for the Healthy Child Programme 0-5.
https://www.gov.uk/government/publications/healthy-child-programme-rapid-review-to-update-evidence
1
UN (2016) Concluding observations on the fifth periodic report of the United Kingdom of Great
Britain and Northern Ireland.
http://www.unicef.org.uk/Documents/Baby_Friendly/Reports/UK%20CRC%20Concluding%20observat
ions%202016%20(2).pdf
1
Davies, S (2013) Chief Medical Officer's annual report 2012: Our Children Deserve Better
https://www.gov.uk/government/publications/chief-medical-officers-annual-report-2012-our-
childrendeserve-better-prevention-pays
1
Davies, S (2014) Annual Report of the Chief Medical Officer 2014, The Health of the 51%: Women
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/484383/cmo-report-
2014.pdf
1
Victora CG, Bahl R, Barros AJD, Franca GVA, Horton S, Krasevec J, Murch S, Sankar MJ, Walker
N, Rollins NC (2016) Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong
effect. The Lancet Series: Breastfeeding 1. Volume 387, No. 10017, p475–490, 30 January
1
Volume 104, Issue Supplement S467, Pages 1–134.
135
1
Renfrew MJ, Craig D, Dyson L, McCormick F, Rice S, King SE, Misso K, Stenhouse E, Williams AF (2009)
Breastfeeding promotion for infants in neonatal units: a systematic review and economic analysis, August,
Health Technology Association.13.No.40
1
Renfrew MJ, Pokhrel S, Quigley M, McCormick F, Fox-Rushby J, Dodds R, Duffy S, Trueman P, Williams T
(2012) Preventing disease and saving resources: the potential contribution of
increasing breastfeeding rates in the UK, UNICEF UK BFI
http://www.unicef.org.uk/Documents/Baby_Friendly/Research/Preventing_disease_saving_resources.pdf
1
Ajetunmobi OM, Whyte B, Chalmers J et al (2014) Breastfeeding is Associated with Reduced Childhood
Hospitalization: Evidence from a Scottish Birth Cohort (1997-2009) The Journal of
Pediatrics.http://www.jpeds.com/article/S0022-3476(14)01065-8/fulltext
1
Strathearn L, Mamun AA, Najman JM, O’Callaghan MJ (2009) Does breastfeeding protect against
substantiated child abuse and neglect? A 15-year cohort study. Pediatrics, Feb 123(2), pp483-93.
1
Borra, C et al (2014) New Evidence on Breastfeeding and Postpartum Depression: The Importance of
Understanding Women’s Intentions. Matern Child Health Journal,DOI 10.1007/s10995-014-1591-z
1
Brown, A., Rance, J. & Bennett, P. (2015). Understanding the relationship between breastfeeding and
postnatal depression: the role of pain and physical difficulties. Journal of Advanced Nursing, DOI:
10.1111/jan.12832
1
Borra, C et al (2014) New Evidence on Breastfeeding and Postpartum Depression: The Importance of
Understanding Women’s Intentions. Matern Child Health Journal,DOI 10.1007/s10995-014-1591-z
1
NICE (2010) Neonatal specialist care (QS4) https://www.nice.org.uk/guidance/qs4
1
NICE (2014) NICE Public Health Guidance 11: Improving the nutrition of pregnant and breastfeeding women
and children in low-income households, Quick Reference Guide: Maternal and child nutrition. Issued March
2008 (updated September 2014).
1
NICE (2015) Postnatal Care up to 8 weeks after birth. (CG37). Issued July 2006. (Updated January, 2015)
https://www.nice.org.uk/guidance/cg37/history
1
NICE (2016) Antenatal care for uncomplicated pregnancies. (CG62), Issue date: March 2008, Updated March
2016 https://www.nice.org.uk/Guidance/CG62
1
PHE (2015) Rapid Review to Update Evidence for the Healthy Child Programme 0-5.
https://www.gov.uk/government/publications/healthy-child-programme-rapid-review-to-update-evidence
1
PHE/Unicef UK (2016) Commissioning Infant Feeding Services
https://www.gov.uk/government/publications/infant-feeding-commissioning-services
1
Volume 104, Issue Supplement S467, pp. 1–134
1
Rollins NC, Bhandari N, Hajeebhoy N, Horton S, Lutter CK, Martines JC, Piwoz EG, Richter LM, Victora CG
(2016) Why invest, and what it will take to improve breastfeeding practices? The Lancet Series: Breastfeeding
2. Volume 387, No. 10017, p491–504, 30 January.
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GP Infant Feeding Network
The GP Infant Feeding Network

Reply to contact@gpifn.org.uk
Viv Bennett
Chief Nurse
Public Health England
West Offices
Station Rise
York
Y01 6GA
26 July 2016
Dear Viv Bennett
Re: Children's public health 0-5 years — review of mandation
We as members of the GP Infant Feeding Network (GPIFN), a UK wide organisation representing

GPs who are working towards best practice in infant feeding, are writing to express our deep
concern over the review and potential removal of mandation for the Universal Health Visitor
reviews in England. Below we outline our reasons:
 Potential Reduction of Health Visitor Services

Universal Health Visitor reviews are a safety-net, for identification of vulnerability. Removal of
mandation will likely result in the loss of this universal protective service for under 5s in areas
where Local Authority cuts to services are planned.
 Risk to Child Protection Efforts

We believe that removal of mandation is inconsistent with the recent CQC recommendation
*more must be done to identify children at risk of harm. The risks to many children are not
always obvious and require a continuous professional curiosity about the child and their
137
circumstances. The emphasis must be on both identifying and supporting those in need of early
help, as well as those at risk of 'hidden' harms".
 Risk to Poverty Reduction and Health Promotion

Around II million children live in England and approximately 2.3 million children are living in
poverty (and can be defined as vulnerable) at the present time- this is expected to rise to 3.6
million by 2020. A further 400,000 children are in need. A sizeable proportion are looked-after
and on the child protection register, and preservation of Universal Health visiting is vital to
enable preventative action to reduce these numbers. There is a real danger that removal of
mandation will lead to increased difficulty to access health care in these groups, increasing
inequity and inequality.
Risk of Reliance on 3rd Sector Services
'Hall 4 - Health for all children' calls for universal joined up multi-professional working. Where
care has not been effective or a critical incident occurs, the findings advise an integrated service
framework and good communication to prevent further instances, Scotland has moved in this
direction to enable the introduction of universal care pathway based on Hall 4 recommendations.
We would welcome a similar strategy adopted across the UK. We believe that removal of
mandation could prompt reliance on third sector involvement, which though valuable in what
can be offered to families, cannot replace a universal screening and safety net and may lead to
fragmentation of service, increasing the likelihood of further critical events in future.
Removing Mandation Conflicts with Recent Public Health Recommendations
Public Health England's report -Health Matters: Giving Every Child the Best Start in Life' (May
2016) makes the case for early years investment and the Healthy Child Programme, including
the mandated Universal Health Reviews and health surveillance. The Healthy Child Programme
can 'ensure families receive early help and support upstream before problems develop further
and reduce demand on downstream, higher cost specialist services'. The report also refers to
research from the London School of Economics and the Centre for Mental Health 'Costs of
Perinatal Mental Health Problems' (October 2014) in stating that 'A failure to act early comes at
great cost, not only to individuals but to society as a whole. The cost of treating perinatal mental
health alone costs £8.1 billion each year'.
Further Risk to Infant Feeding Support
We welcomed the recent The Public Health England report Infant Feeding: Commissioning
Services' (July 2016). Health Visiting services frequently provide breastfeeding support, and we
believe that removal of mandation is highly likely to lead to further cuts to breastfceding
support in Local Authority areas where budget savings are planned. As a network concerned
with support for infant feeding this is extremely concerning, particularly considering cuts to
breastfceding services in England are already occurring. The health and economic costs of low
breastfceding rates in the UK are well documented, including by the recent Lancet
Breastfeeding Series (January 2016).
 Risk of Increasing General Practice Workload

If removal of mandation occurs and Health Visiting services experience cut to budgets, child
health issues that are currently addressed in a systematic way by Health Visitors will require
management by the GP, or may be missed altogether, resulting in complex late presentations.
Our network is also concerned with the current extreme workload pressures in General Practice
and any risk of this increasing further would mean a potentially unsafe reactive service. We are
concerned that individual GPs and Practice Nurses are not being consulted on changes to the
Health Visiting services.
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The Department of Health report 'Universal Health Visitor Reviews: Advice for local authorities in
delivery of the mandated universal health visitor reviews from 1 October 2015' highlighted the six
high impact areas where Health Visitors have a vital role to ensure best outcomes. We strongly
support continuation of this evidence based policy. We therefore recommend that the mandation
is extended in its current form.
Yours Sincerely
Members of the GP Infant Feeding Network Executive Team
Dr Anjali Gibbs General Practitioner MBBChir
Erica Harris
Dr Jennifer Boyd MBChB MRCP DRCOG MRCGP
Dr Louise Santhanam MBBS BSc MRCGP DRCOG
Dr Rachel Barnes MBChB BSc MRCGP DFSRH DRCOG
Dr Samantha Ross MBChB DRCOG MRCGP MRCPCH
Dr Sarah Little MBChB BSc (Hons) MRCGP DCH DRCOG DFSRH
Dr Sarah Khan MBBS MRCGP BSc (Hons) DRCOG DFSRH
Members of the GP Infant Feeding Network
Dr Alison Smith General Practitioner Coventry
Carmen Pagor IBCLC, St George's Specialist Breastfeeding Health Visitor and Children's Centre
Lead Battersea
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Various - Open letter to the Editor of the Times
The nation’s health is at stake
Sir:
Health visitors play a crucial role in improving the health of the nation, yet there have been alarming
reports of imminent cuts to their numbers.
With the health service facing an ever increasing demand for its services, health visitors have a vital
and unique role in preventing ill health and offering universal advice and support to all families.
However, cuts to Local Authority budgets have left many teams and their client families facing an
uncertain future.
The loss of health visitor posts could have irredeemable consequences for children and families,
while stunting the progress of several key Government priorities; from reducing the dangerous levels
of obesity and mental health issues – in children and adults – to promoting social inclusion.
Any money saved by reducing health visitors would simply be eclipsed by the resulting added
pressure on the NHS. Meanwhile, the previous Government’s Health Visitor Implementation Plan
which boosted the health visiting workforce by more than 4,000, would become a wasted
investment should positions be cut.
We call on the Government to secure funding for health visiting services, and protect their
fundamental contribution to health care in the UK.
Janet Davies, Chief Executive and General Secretary, RCN

Dr Cheryll Adams CBE, Executive Director, Institute of Health Visiting
Obi Amadi, Lead Professional Officer (strategy, policy and equalities), Unite
Professor Maureen Baker CBE, Chair of the Royal College of GPs
Professor Woody Caan, Professorial Fellow of the Royal Society for Public Health
Dr Carol Ewing, Vice President for Health Policy, RCPCH
Anna Feuchtwang, Chief Executive, National Children’s Bureau
Dr Rajalakshmi Lakshman, Consultant in Healthcare & Children’s Public Health
Dr Crystal Oldman, Chief Executive, Queen’s Nursing Institute (QNI)
Jeremy Todd, Chief Executive, Family Lives
Peter Wanless, CEO, NSPCC
140
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National Health Visitor Programme –

About Public Health England

Public Health England

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© Crown copyright 2016

Published August 2017

Executive summary ............................................................................................................... 4

 This is a retrospective evaluation of the benefits of the National Health Visitor

 In February 2011, the Department of health published the ‘Health Visitor

 A sustainable benefits realisation approach has been delivered by embedding

 Foundation (2010) – policy commitments, service vision, stakeholder engagement

The initial work programme included three main themes, as follows

 Healthy 2 year olds & school readiness

 improving access to services

Workforce: Health visitor numbers in the workforce

Service delivery: health visiting service delivery metrics

 percentage of New Birth Visits (NBVs) completed within 14 days

Health outcomes: PHE’s early years’ profiles

High impact area Outcome indicator Status

Transition to parenthood Teenage pregnancy rates Established

Low birth weight of term babies Established

Maternal (perinatal) Maternal mental health In

Healthy weight Excess weight at 4-5 years Established

Managing minor illnesses A&E attendance rates, under 5 Established

Inequalities in health outcomes

 Inequality gap – deprivation

 Inequality gap - other

Stakeholder views: survey of key stakeholders

Stakeholder Individual role Distribution via

Local authority Chief executive Society of Local Authority Chief

 Published journal articles, sources such as Community Practitioner

 Case studies published by the Institute of Health Visiting

 Case studies published by individual organisations in order to share best practice

 Through professional networking

Service user experience

Results and discussion

Service delivery: health visiting service delivery metrics

Statistical tests have been applied to all information on service delivery,

Table 2: Summary of trends in health visitor service delivery in England from

Summary of Health Visitor Service Delivery Metrics for England

Overall trends through transfer: Improving

2013/14 2014/15 2015/16 2016/17

C2: Percentage of New Birth Visits (NBVs)

C3: Percentage of New Birth Visits (NBVs)

C4: Percentage of 12 month development

C6i: Percentage of 2-2½ year reviews

C6ii: Percentage of 2-2½ year reviews

Figure 2a: Trends in service coverage, new birth visits

C2: Percentage of New Birth Visits (NBVs) completed within 14 days

Figure 2b: Trends in service coverage, 1 year review

Figure 2c: Trends in service coverage, 2-21/2 year review

C6i: Percentage of 2-2½ year reviews completed

Table 3: Summary of trends in health visitor service delivery in England

Summary of Health Visitor Service Delivery Metrics for England

Overall trends through transfer: Improving

C2: Percentage of New Birth Visits (NBVs)

C3: Percentage of New Birth Visits (NBVs)

C4: Percentage of 12 month development

C6i: Percentage of 2-2½ year reviews

C6ii: Percentage of 2-2½ year reviews

Although the mandation of service requires a new birth visit to be

Commentary from the stakeholder survey explains that parental engagement is

and this tailing off is shown in the coverage statistics.

Region Overall trend in service delivery