Summary of the impact

Evidence about the need for and provision of health visiting services generated through research undertaken at King's College London (KCL) has underpinned major changes in national policies for health visiting. Our findings about health visitors' practice, availability and distribution of services and effectiveness in terms of parenting/child outcomes, revealed both shortfalls in provision and opportunities for improvement and led to the development of a new caseload weighting tool and funding model for service planning. The accumulated evidence from this research helped convince the UK Government in 2010 to commit to 4,200 more health visitors by 2015 — a workforce expansion of nearly 50% — in a time of austerity and restraint elsewhere in the public sector.

Underpinning research

There is increasing awareness of the importance of early life experience (from pregnancy through the pre-school years) for children's development and later health. In the UK, health visitors are the professional group charged with supporting this life stage, through a universal service designed to support the health development of pre-school children and with a wider aim of promoting public health and reducing health inequalities.

Studies of health visiting undertaken at King's College London (KCL) and led by Professor Dame Sarah Cowley (Professor of Community Practice Development, 1997-2012; Lecturer/Senior Lecturer 1992-97) (a) identified specific approaches to health visiting practice and service organisation that are required to support uptake and effectiveness; (b) revealed a lack of relationship between the number of health visitors, distribution of health visiting services and need for those services at local level (as measured by indices of area deprivation); and (c) showed that reduced numbers of health visitors and decreasing access to the universal health visitor service were preventing access to beneficial early interventions for children who needed them.

Research at King's has highlighted the uneasy relationship between health visiting as a proactive and preventive public health service and the overall orientation and structure of the NHS, which is more geared to dealing with acute or chronic illness and responding to problems once they become evident, than to preventing illness and maintaining positive health. In our theory-building research we demonstrated the importance of the health-creating, relational and proactive nature of health visiting, a form of support that is not easily accounted for within NHS commissioning and information systems designed to deal with circumscribed episodes of care. This research revealed the organisational challenges of identifying suitable guidelines or indicators for the quality of preventive services, which cannot be gauged by conventional measures of change or responsiveness to treatment (Refs 1 & 2) In further work we were able to specify more clearly the particular skills and processes involved in health visiting practice — especially when assessing need for this form of health promoting, preventive work — and to demonstrate the importance for effective practice of practitioners having appropriate relational and analytic skills and breadth of knowledge about families and child development, as well as public health (Refs 3 & 4).

Between 2004 and 2010, the number of health visitors in post fell by more than 20% following closure of the health visiting register, changes to the recommended child health promotion strategy and renewed emphasis on NHS targets for dealing with specific illnesses. During the same period, the birth rate rose by approximately 20%, so increasing demand at a time of service contraction. By analysing patterns of service organisation and practice, KCL researchers revealed a significant lack of fit between the availability and distribution of health visitors and the need for their services, which is greater in areas of high deprivation. The role of health visiting in helping to reduce health inequalities was thereby compromised and children's health needs were not being met (Ref 5). These findings, together with insights from the earlier research, were used to develop a funding model and caseload weighting tool for service planning, by identifying time required for key activities and a method of linking staff distribution to area deprivation. This work was influential in convincing the Government to increase the number of health visitors (Refs 6 & 7). Through combining raw data from a 2007 survey of parents conducted by the Family and Parenting Institute (FPI) with health visiting survey data collected in the same year (Ref 8), we established convincing evidence of the ad hoc nature of service distribution. This additional analysis strengthened the findings of the consumer survey, adding rigour and providing the credibility needed to influence policy (Ref 5).

References to the research

Supporting grants:

• Responding to the `Call to Action': Programme of work to support the Health Visitor Implementation Plan Department of Health Policy Research Programme. PI:Maben £769,937, 2011-12.

• How do health visiting services relate to levels of deprivation or availability of other services in an area, or are other factors are influential? Burdett Trust for Nursing. PI: Cowley. £15,926, 2007.

• Determining future directions for health visiting: a scoping census of health visitor registrants Florence Nightingale School of Nursing & Midwifery (special research funds) PI: Cowley. £25,000; CPHVA, £3000. 2004-05.

• Health visiting in partnership project: an investigation of partnership working and decision making in relation to `Extra Health Visiting' and outcomes of care in Community Health South London Health Services NHS Trust Guys & St Thomas' Charitable Foundation. PI: Cowley. £46,709. 2000-01.

• An exploration of the extent to which the health visitor assessment process promotes the health of the families involved. Florence Nightingale School of Nursing & Midwifery (special research funds) PI: Cowley £34,899. 2000-01.

• Family Health Needs Project. SETRHA Primary Care Development Fund, PI: Cowley. £80,029. 1994-96.

Details of the impact

In 2008, Parliament's Health Select Committee reported on an inquiry into the NHS and Health Inequalities, to which Professor Dame Sarah had given evidence about KCL research showing the inequitable distribution, funding and implementation of health visiting services in relation to area deprivation (Source 1). She also presented a report on these topics to the Early Years Commission, established in 2008 by the Centre for Social Justice, a Conservative-leaning think tank which included several references to KCL research (Source 2). Professor Dame Sarah's testimony to these two inquiries, and the research studies she mentioned, were cited in the Conservative Research Department's Helping New Families policy document, which set out its vision for a universal health visiting service (Source 3). This document supplied the rationale for the Conservative Party's manifesto pledge to increase the number of health visitors by 4,200. The manifesto pledge was carried forward by the new Coalition government and included in its 2010 Spending Review, despite the general commitment to a 20% reduction in public spending.

The KCL research studies underpinning Professor Cowley's report also provided core evidence for the UK Public Health Association's (UKPHA) report Health Visiting Matters, which was developed in collaboration with Professor Cowley and launched at the House of Commons in November 2009 (Source 4). The UKPHA was an independent voluntary organisation that acts as an information platform to support people working in public health, now part of the Faculty of Public Health. Health Visiting Matters discussed a number of challenges including the need for secure funding, criteria for best practice, a stronger evidence base for health visiting and future options for employment, education and recruitment.

The Community Practitioners' and Health Visitors' Association (CPHVA) was also very active in lobbying prior to the 2010 election, and some of its publications are cited in Helping New Families. As part of the Department of Health's Action on Health Visiting programme set up in 2009, the CPHVA published a report entitled Getting it right for children and families: Defining research to maximise the contribution of the health visitor. That report cited several KCL studies as instances of good practice (for example Cowley et al, 2007 is discussed as an existing data source available to influence health visitor service development )(Source 5) Additionally, in its document Exploring the role of the Health Visitor and the Registered Nurse in the Health Visitor Team and the Health Visiting Service (Source 6) the CPHVA drew on KCL findings regarding health visiting assessment processes to recommend that, while registered nurses could contribute to the health visiting service, their role should not go beyond the boundaries of their training.

The interim workforce/funding and caseload weighting models developed at King's led to widespread acceptance of the need for more health visitors and for their numbers to be distributed equitably. These models have been used in a number of local Trusts and by at least three Strategic Health Authorities (East of England, North West, London) (Source 7). This was the `public face' of KCL work, which became known through the policy evidence outlined above, but which drew on a far wider body of knowledge and understanding about health visiting developed over two decades of research. Our standing in this field was summarised in a local authority scrutiny review of health visiting as follows: `The reason that Prof Cowley's model has been chosen is that she is the academic who has nationally done the most work in this field and is always quoted in the work by e.g. Commons Select Committees etc.,' (Source 8, para 107 page 31).

It is arguable, therefore, that the government's commitment to expanding the health visiting workforce was influenced by the whole body of research at King's. The significance of Professor Cowley's work in this field was noted in her DBE citation, where the academic research she led was described as having, "created the evidence base for modern health visiting. She has ensured that this research has been translated into practice to improve health outcomes for children, families and communities and has been an especial champion for the most vulnerable families."

Once in power, the Coalition government developed its own Health Visitor Implementation Plan (Source 9), aimed at growing the workforce, mobilising the profession and aligning delivery systems. This report heavily cited KCL research regarding the health visitor's `journey' with a client and how best it should be initiated and developed, and the need to retain health visiting services in forms that would help people most in need. To support the plan, the DH Policy Research Programme commissioned researchers at KCL to undertake a programme of research into the provision of health visiting services under the leadership of Professor Jill Maben (Professor of Nursing Research 2011-present; Senior Research Fellow 2007-2011.) and Professor Cowley. Outputs from this programme included a literature review which confirmed the findings from KCL research on the importance of service organisation and the skills, attributes and values of health visitors in promoting access to and uptake of the service (Source 10).

In February 2013 according to the NHS Information Centre for Health and Social Care, 1000 more health visitors had been employed (now 9113) than the baseline figure at May 2010 (Source 11).

Sources to corroborate the impact

Source 1 Cowley S (2008) Memorandum by Professor Sarah Cowley (HI 76) The contribution of the NHS to reducing health inequalities. House of Commons Health Committee. Health Inequalities. Written Evidence Session 2007-08, Volume II, pages 256-261 HC 422-II (http://www.parliament.the-stationery-office.co.uk/pa/cm200708/cmselect/cmhealth/422/422we228.htm)

Source 2 Cowley S (Prepared 3.3.2008). The Contribution of the NHS To Reducing Health Inequalities: evidence to the Early Years Commission (Centre for Social Justice): (unpublished — available from author)

Source 3 Conservative Research Department (2008). Helping new families. Support in the early years through universal health visiting. London, Conservative Party.
http://www.conservatives.com/~/media/Files/Downloadable%20Files/Helping%20new%20families.ashx

Source 4 UKPHA Health Visiting Matters:
http://www.rcn.org.uk/__data/assets/pdf_file/0011/288290/health_visiting_matters_final_report.pdf

Source 5 Getting it right for children and families: Defining research to maximise the contribution of the health visitor:
http://archive.unitetheunion.org/pdf/Job%202520%20Action%20on%20Health%20Visiting%20v2.pdf

Source 6 Exploring the role of the Health Visitor and the Registered Nurse in the Health Visitor Team and the Health Visiting Service : http://archive.unitetheunion.org/pdf/HealthVisitorRole.pdf

Source 7 Examples of use of caseload weighting:

• NHS London's Health Visiting Trajectories and Impact on Hounslow (2012):
  http://democraticservices.hounslow.gov.uk/(S(0jvmmq45oktuyd55cs22ct45))/mgConvert2PDF.aspx?ID=71887
• NHS Tayside. Appropriate and equitable distribution of Health Visiting resources to meet population need in Dundee:
  http://www.nhstayside.scot.nhs.uk/about_nhstay/commitees/05_dchp/27082009/docs_038100.pdf
• NHS North Yorkshire and York (2012). North Yorkshire County Council Children and Young People Overview and Scrutiny Committee:
  https://www3.northyorks.gov.uk/n3cabinet_scru/youngpeople_/reports_/20120914_/06progressrepor/06progressrepor.pdf
• NHS Great Yarmouth and Waveney Community Services. Universal Services for 0-5 Year Olds (Health Visiting). A Review and Scoping Exercise:
  http://www.gywpct.nhs.uk/_store/documents/paper_5_hv_review.pdf

Source 8 London Borough of Hounslow (2010) Scrutiny Review of Health Visitor Numbers Report of the Children and Young People Scrutiny Panel. Hounslow, London Borough of Hounslow. http://democraticservices.hounslow.gov.uk/Published/C00000262/M00005420/AI00052984/HealthVisitorNumbersScrutinyReviewFinal.pdf

Source 9 Health Visitor Implementation Plan 2011-2015: A Call to Action. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/134763/dh_131064.pdf.pdf

Source 10 This document was supported by the following literature review: Cowley S. Whittaker K, Grigulis A, Malone M, Donetto S, Morrow E, Maben J. (2013). Why Health Visiting? A review of the literature about key health visitor interventions, processes and outcomes for children and families. London. National Nursing Research Unit, King's College London:
http://www.kcl.ac.uk/nursing/research/nnru/publications/Reports/Why-Health-Visiting-NNRU-report-12-02-2013.pdf

Source 11 NHS Information Centre for Health and Social Care (2013) NHS Hospital & Community Health Service (HCHS) monthly workforce statistics — Provisional Statistics: Minimum Data Set (MDS) collection for Health Visiting (HV) http://www.hscic.gov.uk/article/2021/Website-Search?productid=11621&q=Health+visitor+Minimum+data+set&sort=Relevance&size=10&page=1&area=both#top