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Health visitor numbers in England fell from a high of 10,500 in 1998 to a low of 7,700 in 2011 as retirements hit the workforce hard.
Rather than concentrating on core early-age preventive work, the lower workforce numbers forced health visitors into firefighting mode - called in when families reach a critical low point.
Speaking to health visitors in the 150th anniversary year of the service, health minister Anne Milton said she believes that if health visitors could return to early prevention work with all children and families, 'real rewards would be seen 15 years down the line'.
Since 2011 the government's Call to Action programme has promoted a new service vision and four-stage model of health visiting practice (see box). It has also made a concerted effort to expand the workforce by 4,200 by 2015.
The first cohorts of newly qualified health visitors recruited through the programme are due to start work in September. One year into the strategy, 26 organisations, called early implementer sites (EIS), are supporting existing health visitors to deliver the new model. A further 23 sites were announced in June.
Nurse consultant in public health Janette Hopkins, lead commissioner for health visiting at NHS Blackpool, has been working with her colleague Teresa Waleboer to resolve a range of perinatal poor health issues. 'Blackpool is a town of high deprivation, which means health visitors' workload is high,' explains Ms Waleboer, head of children and family services for Blackpool Teaching Hospitals NHS Foundation Trust.
Ms Hopkins says: 'We had serious public health needs yet I could see that the health visitor service was not tied into the public health philosophy. Although health visitor numbers in the trust were not too low, they were undertaking a lot of safeguarding work. It seemed counterintuitive to ask health visitors to focus on preventive work because it might eventually scale down the "universal plus service" (see box below) we were committed to.'
Ms Hopkins says the national Call to Action programme is giving health visitors the resources to use evidence about early intervention systematically. 'We now have a health visitor on the board of every children's centre and we are adopting the "universal service", including the Healthy Child Programme. Additional health visitor numbers mean we have been able to implement projects such as a perinatal mental health programme.'
Health visitor and infant feeding lead Clare Whitehead was recruited to Wirral Community NHS Trust because the local primary care trust scored low on the breastfeeding league tables.
She says: 'It is not effective to keep telling women to breastfeed, so I tried to understand when women need support the most; it is in the middle of the night and in the evenings - just when there is no advice available.
'The most disengaged group - young mums - all use smartphones. So with my IT colleague, we developed a simple breastfeeding app. We only launched the app in June but it is proving to be a big hit.'
In Portsmouth, Solent NHS Trust service manager for children and families Jenny Gilmour realised that there was scope for health visitors to improve the quality and coverage of the healthy child programme. This offers every family screening tests, immunisations, developmental reviews and parenting information.
'Being selected as an EIS and the prospect of more health visitors entering the workforce in September as the first cohort of new recruits graduate, meant that we could implement two projects,' Ms Gilmour says.
'The first is the preparation for birth and beyond course. The second aims to improve the quality and coverage of the two-year developmental review.
'It has not been easy,' admits Ms Gilmour. 'Health visitor numbers have not yet increased; we have been training the additional students and investing in leadership and other new skills for the existing workforce.'
'But soon, we will be able to reduce caseload sizes and start working in an anticipatory rather than an interventionist capacity,' she says.
Like her colleagues in Blackpool and Wirral, Ms Gilmour also foresees a time when early help for all will prevent families needing the reactive approach and reduce the need for intensive safeguarding.
The government's health visitor implementation plan: tinyurl.com/7xn666k
One year on - a progress report: tiny.cc/one_year_on
Health visitor recruitment: tinyurl.com/BecomeHV