Health visiting – a Health visiting – a universal service for universal service for

the future?the future?Phil WilsonPhil Wilson

General practice and primary General practice and primary carecare

University of GlasgowUniversity of Glasgow

Why is a GP giving this talk?Why is a GP giving this talk?

Why health visiting is Why health visiting is important – the power of early important – the power of early

interventionintervention David Olds – 3 randomised controlled trials in US David Olds – 3 randomised controlled trials in US

with long-term follow-upwith long-term follow-up 1998 – 15-year follow up of 400 “high-risk” 1998 – 15-year follow up of 400 “high-risk”

children in New Yorkchildren in New York Nurse-Family Partnership (NFP)Nurse-Family Partnership (NFP) Intervention was 9 antenatal and 23 postnatal Intervention was 9 antenatal and 23 postnatal

nurse visits before age 2 nurse visits before age 2 Vs Vs control – addressing:control – addressing: General health promotionGeneral health promotion Maternal personal developmentMaternal personal development ““Competent care of their children”Competent care of their children”

The power of early The power of early intervention.intervention.

Compared with controls, adolescents born to Compared with controls, adolescents born to women who received nurse visits during pregnancy women who received nurse visits during pregnancy and postnatally displayed fewer:and postnatally displayed fewer: instances of running away (0.24 instances of running away (0.24 VsVs 0.60; 0.60;

P=.003), P=.003), arrests (0.20 arrests (0.20 VsVs 0.45; P =.03), 0.45; P =.03), convictions and violations of probation (0.09 convictions and violations of probation (0.09 VsVs

0.47; P<.001),0.47; P<.001), lifetime sex partners (0.92 lifetime sex partners (0.92 VsVs 2.48; P=.003), 2.48; P=.003), cigarettes smoked per day (1.50 cigarettes smoked per day (1.50 VsVs 2.50; P=.10), 2.50; P=.10), days having consumed alcohol in the last 6 days having consumed alcohol in the last 6

months (1.09 months (1.09 VsVs 2.49; P =.03). 2.49; P =.03). reported behavioural problems related to use of reported behavioural problems related to use of

alcohol and other drugs (0.15 alcohol and other drugs (0.15 VsVs 0.34; P=.08). 0.34; P=.08).

The power of early The power of early interventionintervention

Key messages from Olds’ trials: Key messages from Olds’ trials: Long term outcomes were generally better Long term outcomes were generally better

than short term onesthan short term ones Highly cost effectiveHighly cost effective Nurses more effective and acceptable than Nurses more effective and acceptable than

“paraprofessionals”“paraprofessionals” Interventions produce lasting effects on the Interventions produce lasting effects on the

mother’s life course as well as the child’smother’s life course as well as the child’s Some lack of clarity about which elements of Some lack of clarity about which elements of

the intervention are importantthe intervention are important Gains might be lower in low risk groupsGains might be lower in low risk groups Continuity of care really matters (unpublished Continuity of care really matters (unpublished

data)data)

Would we get the same results Would we get the same results if we transplanted NFP to the if we transplanted NFP to the

UK?UK? Probably not!Probably not!

We already have a HV serviceWe already have a HV service UK studies comparing standard HV UK studies comparing standard HV

service with enhanced HV input (eg service with enhanced HV input (eg Wiggins 2005, Starting Well) have Wiggins 2005, Starting Well) have produced little evidence of substantial produced little evidence of substantial gain gain

but some work in progress – eg Family Nurse but some work in progress – eg Family Nurse Partnership pilotsPartnership pilots

So what are the key elements So what are the key elements of UK health visiting?of UK health visiting?

In common with NFP:In common with NFP: Health led (Sure Start evaluation)Health led (Sure Start evaluation) Delivered by nursesDelivered by nurses Continuity of careContinuity of care

The UK contribution:The UK contribution: Professional judgement about level and Professional judgement about level and

type of inputtype of input Universal serviceUniversal service

Policy responsesPolicy responses

Hall 4Hall 4 Review of Nursing in the Community Review of Nursing in the Community

(RONIC)(RONIC) The Glasgow Health Visiting ReviewThe Glasgow Health Visiting Review

Hall 4Hall 4

““PCOs should plan how PCOs should plan how to discharge their to discharge their responsibility for the responsibility for the health care of all the health care of all the children and young children and young people living within people living within their boundaries”their boundaries”

““Screening, Screening, surveillance, parent surveillance, parent support and health support and health promotion activities promotion activities should, where possible, should, where possible, be prioritized on the be prioritized on the basis of evidence of basis of evidence of effectiveness”effectiveness”

Hall 4Hall 4

Key recommendations in relation to HV:Key recommendations in relation to HV: Reduction in screening activityReduction in screening activity Allocation of families to Core / Additional / Allocation of families to Core / Additional /

Intensive statusIntensive status End of End of universaluniversal face-to-face screening face-to-face screening

contacts after 8 weeks (though some contacts after 8 weeks (though some contact kept with children through contact kept with children through immunisation, nursery visits, phone calls immunisation, nursery visits, phone calls etc)etc)

Hall 4Hall 4

Many of Hall 4 recommendations are Many of Hall 4 recommendations are now out of date:now out of date: New research on early social development New research on early social development

and developmental trajectoriesand developmental trajectories New research on identifying problemsNew research on identifying problems New research on screeningNew research on screening New research on effective early parenting New research on effective early parenting

support interventionssupport interventions

Hall 4 update: New research on early Hall 4 update: New research on early social development and developmental social development and developmental

trajectoriestrajectoriesMany examples, eg Morrell and Murray 2003:

Hall 4 update: New research on Hall 4 update: New research on identifying problemsidentifying problems

Hall 4 update: new research on Hall 4 update: new research on screeningscreening

Miniscalco et al 2006: Miniscalco et al 2006: Simple screen for language delay at 2.5 Simple screen for language delay at 2.5

yearsyears 2% already known to have developmental 2% already known to have developmental

delay so excludeddelay so excluded 4% (25/625) of the rest had <50 words or no 2 4% (25/625) of the rest had <50 words or no 2

word utterancesword utterances Follow up examinations at 6 and 7 yearsFollow up examinations at 6 and 7 years 70% who failed the screen had major 70% who failed the screen had major

neuropsychiatric disorders (ADHD, ASD or neuropsychiatric disorders (ADHD, ASD or other learning difficulties). All of these other learning difficulties). All of these required additional educational, health or required additional educational, health or SW servicesSW services

Hall 4 update: New research on Hall 4 update: New research on effective early parenting support effective early parenting support

approachesapproaches

Triple-PTriple-P Webster-Stratton Incredible YearsWebster-Stratton Incredible Years Mellow Parenting and Mellow BabiesMellow Parenting and Mellow Babies

Hall 4 implementationHall 4 implementation

Variable in Scotland, but local Variable in Scotland, but local implementation strategies generally based implementation strategies generally based on:on: Early risk stratificationEarly risk stratification Geographical team working with team leaders Geographical team working with team leaders

making decisions about core/additional/intensive making decisions about core/additional/intensive statusstatus

Skill-mix team workingSkill-mix team working End of universal contacts at 8-16 weeksEnd of universal contacts at 8-16 weeks

This has contributed to major de-motivation This has contributed to major de-motivation of HV workforce and falling numbers of HVsof HV workforce and falling numbers of HVs

Review of Nursing in the Review of Nursing in the CommunityCommunity

““Visible, Accessible and Integrated care” Visible, Accessible and Integrated care” 2006 (draft)2006 (draft) Based on problems of the aging populationBased on problems of the aging population Creation of Community Nurse roleCreation of Community Nurse role Abolition of health visiting, district nursing and Abolition of health visiting, district nursing and

school nursingschool nursing No widely available community nursing No widely available community nursing

workforce with a focus on childrenworkforce with a focus on children Geographically based teams with no clear links Geographically based teams with no clear links

to general practicesto general practices

RONICRONIC

Children barely mentionedChildren barely mentioned No evidence base presentedNo evidence base presented Likely to fragment the primary care team Likely to fragment the primary care team

and holistic family careand holistic family care Likely to cause confusion amongst the Likely to cause confusion amongst the

most vulnerable most vulnerable No clarity about communication and No clarity about communication and

record keepingrecord keeping Little clarity on accountability and inter-Little clarity on accountability and inter-

agency workingagency working

RONICRONIC

4 pilot sites4 pilot sites End of HV training in some areas, End of HV training in some areas,

replacement with generic community nurse replacement with generic community nurse trainingtraining

Evaluation approach not clearEvaluation approach not clear ““Staff remain confused and concerned Staff remain confused and concerned

about the pilot plans” (Linda Pollock)about the pilot plans” (Linda Pollock) Recommendations to Scottish Government Recommendations to Scottish Government

by April 2009by April 2009

The Glasgow Health Visiting The Glasgow Health Visiting ReviewReview

Conceived Conceived out of concern at the RONIC model’s disregard out of concern at the RONIC model’s disregard

for childrenfor children because of health-social work joint working in because of health-social work joint working in

CHCPsCHCPs because of failures and understaffing in child because of failures and understaffing in child

protection services in Glasgow: protection services in Glasgow: ““Focus on the most vulnerable”Focus on the most vulnerable” Lack of understanding that generalist services Lack of understanding that generalist services

prevent many families needing intensive or prevent many families needing intensive or specialist servicesspecialist services

Lack of acknowledgement of the risk of a Lack of acknowledgement of the risk of a stigmatised servicestigmatised service

The Glasgow Health Visiting The Glasgow Health Visiting ReviewReview

Meetings held in secret – no minutes Meetings held in secret – no minutes keptkept

No input from professionalsNo input from professionals No input from parentsNo input from parents Poor quality literature reviewPoor quality literature review Implementation before report Implementation before report

publishedpublished Token consultation exerciseToken consultation exercise

The Glasgow Health Visiting The Glasgow Health Visiting ReviewReview

Recommendations:Recommendations: End of universal contact at 4 monthsEnd of universal contact at 4 months End of HV attachment to general End of HV attachment to general

practicespractices Multi-professional, social work-led Multi-professional, social work-led

geographical teamsgeographical teams Corporate caseloadsCorporate caseloads ““Skill mix”Skill mix” End of administration of immunisations End of administration of immunisations

by HVsby HVs

The Glasgow Health Visiting The Glasgow Health Visiting ReviewReview

Massive opposition from parents and Massive opposition from parents and professionalsprofessionals 5000+ individual protest letters to Health 5000+ individual protest letters to Health

BoardBoard 21,000+ signatures on Holyrood petitions21,000+ signatures on Holyrood petitions HB negotiations with GP and HV HB negotiations with GP and HV

representativesrepresentatives Review is defunct in all but nameReview is defunct in all but name

Where to now in Glasgow?Where to now in Glasgow?

Things do need to change:Things do need to change: We need a HV service based on We need a HV service based on

evidenceevidence We need to be able to show that the HV We need to be able to show that the HV

service worksservice works We need a service that responds to the We need a service that responds to the

needs of both parents and childrenneeds of both parents and children

The Glasgow Parenting Support The Glasgow Parenting Support FrameworkFramework

UNIVERSAL INTERVENTIONS

NO INTERVENTION INTERVENTION

ACTIVE FILTERING

ADDITIONAL ASSESSMENTS

Parents and professionals both

believe no problems.

Parent or professionals

believe there are problems.

Parents and professionals

believe there are problems.

Defaulters and families with continuing problems at HV

assessmentSPECIALIST SERVICES

Active filtering by HVsActive filtering by HVs Partnership between parents/carers and Partnership between parents/carers and

professionals.professionals. Parents: Parents:

Generally “know when something is wrong”Generally “know when something is wrong” With the childWith the child With themselvesWith themselves With the relationshipWith the relationship

Early identification of neurodevelopmental problems is Early identification of neurodevelopmental problems is importantimportant

Because it’s good for parentsBecause it’s good for parents Because early intervention works bestBecause early intervention works best

Professionals…Professionals…

Active filtering by HVsActive filtering by HVs HVs’ decision-making about families is already HVs’ decision-making about families is already

complex:complex: Depend on personal background, demographics of Depend on personal background, demographics of

practice, inter- and intra-professional relationshipspractice, inter- and intra-professional relationships Crucially dependent on development and continuity Crucially dependent on development and continuity

of relationship with familiesof relationship with families Major weakness lies in lack of training to evaluate Major weakness lies in lack of training to evaluate

the the relationshiprelationship between parent and child between parent and child formallyformally

Evaluation of the relationship important because Evaluation of the relationship important because its quality predicts outcome for children its quality predicts outcome for children independently of problems in parent or childindependently of problems in parent or child

Formal evaluation important for effective inter-Formal evaluation important for effective inter-agency communicationagency communication

Proposed universal HV Proposed universal HV contactscontacts

Brazelton NBAS at 1st visitBrazelton NBAS at 1st visit 6-8 week postnatal examination6-8 week postnatal examination 13 month assessment evaluating parental 13 month assessment evaluating parental

wellbeing and parenting difficultieswellbeing and parenting difficulties Contact at 2½-3 years for language and Contact at 2½-3 years for language and

motor screening, and assessment of child motor screening, and assessment of child psychological wellbeing psychological wellbeing Possibly by phone or postal questionnairePossibly by phone or postal questionnaire Possibly in collaboration with nurseries on Possibly in collaboration with nurseries on

entryentry And an “open door” to familiesAnd an “open door” to families

Operating, monitoring and Operating, monitoring and evaluating the Frameworkevaluating the Framework

Use of structured tools by HVs in Use of structured tools by HVs in collaboration with families:collaboration with families: Edinburgh postnatal depression scale (8-12 weeks)Edinburgh postnatal depression scale (8-12 weeks) Parenting daily hassles (13 and 30 months)Parenting daily hassles (13 and 30 months) Adult wellbeing scale (13 months)Adult wellbeing scale (13 months) Language screen (30 months)Language screen (30 months) Eyberg Child Behavior Inventory (30 months)Eyberg Child Behavior Inventory (30 months) Strengths and Difficulties Questionnaire (36 Strengths and Difficulties Questionnaire (36

months?)months?) And satisfaction data from families and And satisfaction data from families and

professionals etcprofessionals etc

What do you think?What do you think?

Does collection of structured data on Does collection of structured data on parenting and child wellbeing: parenting and child wellbeing: Focus service priorities in the right way?Focus service priorities in the right way? Increase access to services for those Increase access to services for those

who need it most?who need it most? Help make the case for investment in Help make the case for investment in

early years support?early years support? Or does it risk alienating families and Or does it risk alienating families and

professionals?professionals?