Presentation by Emeritus Professor Dame Sarah Cowley at the Institute of Health Visiting Regional Professional Conferences 2015 - London Emeritus Professor Dame Sarah Cowley is a Trustee of the Institute of Health Visiting.

1. Health visiting as a
proportionate universal service
Sarah Cowley
19th March 2015

2. Acknowledgements
Empirical study
Voice of service usersAIMS
Literature review
Narrative synthesis of health
visiting practice
Empirical study
Recruitment and retention
for health visiting
This work was commissioned and supported by the Department of Health in England as
part of the work of the Policy Research Programme. The views expressed are those of
the authors and not necessarily those of the Department of Health.
Presentation available to download from http://fyir.org.uk/events.htm

3. Inequalities in early childhood:
proportionate universalism
• “Giving every child the best start in life is crucial to
reducing health inequalities across the life course.
. . .
• “(We need) to increase the proportion of overall
expenditure allocated (to early years, and it)
should be focused proportionately across the
social gradient to ensure effective support to
parents, starting in pregnancy and continuing
through the transition of the child into primary
school. . . . .”
Marmot (2010 p 23) Fair Society, Healthy Lives

4. Why ‘Foundation Years’?
• Strong, expanding evidence
showing the period from
pregnancy to two years old
sets the scene for later
mental and physical health,
social and economic well-
being
• Direct links to cognitive
functioning, obesity, heart
disease, mental health,
health inequalities and more
• Social gradient demonstrates
need for universal service,
delivered proportionately
• Foundations of health:
• Stable, responsive
relationships
• Safe, supportive
environments
• Appropriate nutrition
www.developingchild.harvard.edu

5. Both. . and. . not . either. . or. .
• Universal and targeting
• Need for targeted services delivered from within
universal provision delivered to all
• Population assessment (commissioner-led) and
family/individual assessment (practitioner-led)
• Different intensities and types of provision
according to individual need
• Generalist health visiting and embedded
specific, evidence based interventions
• Take into account social gradient and
prevention paradox

6. Family Disadvantage Indicators
• No parent is in work
• Family lives in poor quality
or overcrowded housing
• No parent has qualifications
• Mother has mental health
problems
• At least one parent has
longstanding, limiting
illness, disability or infirmity
• Family has a low income
below 60% of the median
• Family cannot afford a
number of food or clothing
items.
• A rise in adverse outcomes for
children becomes evident when
their families experience only one
or two of these seven indicators
• Mapped to children in the Millenium
Cohort Study and area to show
spread across social gradient
• Caution: figures (next) are for
explanation only: they are old
(2000-09) and approximate;
Primary Care Trusts (PCTs) no
longer exist
• Family Disadvantage Indicators
omit key markers, e.g. illicit drug
use, domestic violence and abuse
Social Exclusion Task Force (2007) Reaching Out: Think Family. Analysis from ‘families at risk’ review

7. Children with no Family Disadvantage
Indicators by area disadvantage (IMD 2009)
Social Exclusion Task Force (2007) Think Family: analysis from ‘families at risk’ review

8. Children with Family Disadvantage
Indicators by area disadvantage (IMD 2009)
Social Exclusion Task Force (2007) Think Family: analysis from ‘families at risk’ review

9. Pre-school children: distribution across
Primary Care Trusts (IMD 2009)
ONS 2009

10. Number of children aged 0-5 affected in
each group in each centile
65% of Children - 864,465 35% of
Children -
475,164

11. Obesity prevalence and deprivation
National Child Measurement Programme 2013/14 – Year 6 children
11Patterns and trends in child obesity (note – a similar patternis seen in Reception year)Child obesity: BMI ≥ 95th centile of the UK90 growth reference
Local authorities in England

12. ‘Prevention paradox’
• “A large number of people at small risk may
give rise to more cases of disease than a
small number of people at high risk”
• High risk groups make up a relatively small
proportion of the population
• Need to shift the curve of the gradient and
distribution of need across the whole
population to reduce overall prevalence
Khaw KT and Marmot M (2008) 2nd edition Rose’s Strategy of Preventive Medicine

13. Strengths: capacity and resources
across population

14. Health visitor direct input:
Universal provision, delivered proportionately

15. Health visitors do not work alone

16. Wider community
Neighbourhood
Family
Parent
Child
Children do not live alone (in UK)
Shifting focus of
attention to need
Situation,
resources to meet
need
Simultaneous
assessment,
prevention,
intervention
Bronfenbrenner’s (1986) concept of nested systems

17. Wider community
Neighbourhood
Family
Parent
Child
Health visiting practice
• Focus on situation and resources
needed for prevention and promotion
• Community and caregiver capacity1
• Foundations of health1
Stable, responsive relationships
Safe, supportive
environments
Appropriate nutrition
1www.developingchild.harvard.edu

18. Relational process; focused practice
Bidmead C (2013) http://www.kcl.ac.uk/nursing/research/nnru/publications/Reports/Appendices-12-02-13.pdf
Salutogenic
(health creation)
Person-centred
Person-in-
context

19. Updated Health Visitor Implementation Plan
Growing the
workforce
Professional
mobilisation
Service
transformation

20. Oct 2015: Commissioning of HVs shifts
to Local Government
DH: 4-5-6 model for health visiting

21. For families – universality should mean:
•Universal ‘offer’ of:
• Five mandated contacts: everyone gets this
• Healthy Child Programme (HCP)
• Service on their own terms
•‘Service journey’
• Meet/get to know health visitor: trust relationship,
partnership working – ‘relational autonomy’
• Services delivered to all – i.e., home visits (HCP)
• Health visiting outside home – well baby clinics, groups etc,
in conjunction with others (e.g. Children’s Centres)
•‘Open secret’ of safeguarding/child protection
Cowley et al (2014) http://dx.doi.org/10.1016/j.ijnurstu.2014.07.013

22. ‘Universal Plus:’ simultaneous
prevention and treatment
•Across six high priority
areas and more, e.g.
• Specially trained health
visitors can
simultaneously prevent
Brugha et al 2010, detect and
treat post-natal
depression through
‘listening visits’ Morrell et al
2009
• Post-qualifying training
being rolled out by
Institute of Health Visiting
(Perinatal Mental Health
‘Champions’)

23. Mental health
• Post-natal depression (PND)
• Early identification and treatment with listening
visits Morrell et al 2009
• Prevention of PND Brugha et al 2010
• More relaxed mothering Wiggins et al 2005, Barlow
et al 2007, Christie et al 2011
• Improved mother/infant interaction Davis et al
2005, Barlow et al 2007
• Special needs: Reduced children’s ADHD
symptoms and improved maternal well-
being, by HV working in specialist team
Sonuga-Barke et al 2001

24. Universal Partnership Plus
Maternal Early Childhood Sustained Home Visiting (MECSH)
•Designed to capitalise on what is known about
successful programmes
•Sufficient intensity and duration: home visits + groups
•Strengths based practice using ‘family partnership
model’ - FPM (Davis et al 2002)
•Two generational (parent and child) and multi-
faceted/community based
•Highly skilled professionals
•And to add in:
•Support and develop existing, generic service
•‘Shift the curve’ by targeting ‘worst-off’ 20%
Kemp et al ( 2011) Archives of Disease in Childhood 96:533-540.

25. Health visitor research programme
• Literature - evidence of benefits, if
sufficient staff, skills, knowledge
• Health Visitors’ desire to make a
difference for children and families
• Parents’ desire to be ‘known’,
listened to and ease of access
• Shared desire for:
• Others to value their knowledge
and contribution
• Respectful, enabling
relationships
• Flexible service (varied intensity
+ type, e.g. home visits and
centre-based) to match need

26. What is needed?
•Organisational support
•Conflicting demands
•Population needs (e.g., KPIs, targets) vs.
individual/family needs
•Sufficient time
•Staffing levels
•Equipment for job
•Sufficient skills
•Education:
• For qualification/pre-registration health visitor programme
• Continuous professional development

27. Revenue costs
Funding 1999/2000 –
2001/02
£millions
(actual)
2002/03 –
2004/05
£millions
(actual)
2005/06 –
2007/08
£millions
(actual)
2008/09 –
2010/11
£millions
(estimated)
Sure Start
Local
Programmes
141 840 1074 838
Children’s
Centres
0 13 656 2205
Health visitors 965 965 900 840
totals 1106 1818 2630 3883
Source: Audit Commission (2010) Giving Children a Healthy Start

28. Whole time equivalent (WTE) health visitors
employed in England (1988) 1998-2014
10,680
10,020
10,070
10,050
10,046
10,190
9,912
9,999 10,137
9,809
9,376
9,056
8764
8519
8017
7941
8385
9550
10800
7,500
8,000
8,500
9,000
9,500
10,000
10,500
11,000
11,500
12,000
1988
1998
2000
2002
2004
2006
2008
2010
2012
2014
WTE health visitors
Nov 2014 = 11,239
Incl. 501 non-ESR
Target = 12,292 WTE
(May 2015)
ESR = NHS electronic staff record Source: Information Centre for Health and Social Care
*

29. Sufficient time
•What is appropriate level of staffing?
• Family Nurse Partnership caseload = 25 families
• Starting Well = 80-85 families (including skillmix)
• Typical HV caseload = 400+ families, up to 1000
•Funding model Cowley 2007, Cowley and Bidmead 2009
• Recommends range according to levels of deprivation,
between 100 and 400 children per health visitor, not
accounting for skillmix (consensus papers)
•Research about skillmix/teamwork Cowley et al 2013
• Scarce, not linked to outcomes
• Issues about referral, delegation, specialisation

30. Skills and knowledge
•Health visitor programme:
•Open only to registered nurses or midwives
•45 programmed weeks
•50% theory, 50% practice, i.e. 22.5 weeks in each
‘More education needed for. . . .’
• Community development/public health practices, multi-agency/multi-
disciplinary engagement, need for more knowledge about breast feeding and
immunisation, better preparation to promote home safety and unintentional
injury, more/better skills in dealing with post-natal depression and mental
health, better understanding, knowledge and skills for obesity prevention,
health visitors should be better equipped to deal with skillmix, including
delegation, support to develop more skilful, culturally competent practice with
seldom heard groups, including BME populations and those experiencing
current major life problems such as insecure housing or seeking asylum,
sensitivity and skills in enabling disclosure of e.g domestic violence, hidden
needs, able to develop authoritative practice in complex needs, e.g. in child
protection situations . . . . .

31. How to get sufficient skills?
•Post-qualifying –
continuing professional
development
• Better preceptorship for
new/recently qualified and
updates for all
• Cascade training through
Institute of Health Visiting:
• Perinatal mental health
• Infant mental health
• Domestic violence and
abuse
• Etc., etc
•Pre-registration
programme
• The current 45-week
programme is over-full
• Longer/different
approaches needed
• All options need to be on
the table, including a wider
entry gate and direct entry
degree or Masters
programmes

32. Health and Inequalities:
focus on the Foundation Years
• Known importance of
• Caregiver and
Community Capacities
• Foundations of Health
• Biology of Health
•Emerging understandings:
• what is necessary (required) for
child development
• what is foundational: ie, other
elements will not work without it
• how to measure foundations and
requirements (assets/capacity)
• which outcomes are appropriate
and helpful to measure
• connections that exist between
problem-based (prevention) and
capacity-building (promotion)
approaches
• how to delineate attribution
www.developingchild.harvard.edu

33. Policy recommendations
• Marmot’s ‘second
revolution for the early
years’: increase overall
expenditure, focused
proportionately across
gradient
• Build on health visiting
plan successes – don’t
lose the benefits of
2011-15 in transfer to
local government
• Enabling sufficient
health visiting time,
skills, organisation =
• better outcomes
(six high impact
areas)
• flexible/acceptable
service
• both population
health needs and
individual families

34. Thank you!
sarah.cowley@kcl.ac.uk
http://fyir.org.uk/events.htm

35. ‘Why Health Visiting’ References
• Reports on NNRU website: http://www.kcl.ac.uk/nursing/research/nnru/publications/index.aspx
• Bidmead C (2013) Health Visitor / Parent Relationships: a qualitative analysis. Appendix 1, in Cowley S, Whittaker K, Grigulis A, Malone
M, Donetto S, Wood H, Morrow E & Maben J (2013b) Appendices for Why health visiting? A review of the literature about key health
visitor interventions, processes and outcomes for children and families. National Nursing Research Unit, King’s College London
• Cowley S, Whittaker K, Grigulis A, Malone M, Donetto S, Wood H, Morrow E & Maben J (2013a) Why health visiting? A review of the
literature about key health visitor interventions, processes and outcomes for children and families. National Nursing Research Unit,
King’s College London
• Cowley S, Whittaker K, Grigulis A, Malone M, Donetto S, Wood H, Morrow E & Maben J (2013b) Appendices for Why health visiting? A
review of the literature about key health visitor interventions, processes and outcomes for children and families. National Nursing
Research Unit, King’s College London
• Donetto S, Malone M, Hughes, Morrow E, Cowley S, J Maben J (2013) Health visiting: the voice of service users. Learning from service
users experiences to inform the development of UK health visiting practice and services. National Nursing Research Unit, King’s
College London
• Whittaker K, , Grigulis A, Hughes J, Cowley S, Morrow E, Nicholson C, Malone M & Maben J (2013) Start and Stay: the recruitment
and retention of health visitors. National Nursing Research Unit, King’s College London
• Policy+ 37: February 2013 - Can health visitors make the difference expected?
http://www.kcl.ac.uk/nursing/research/nnru/Policy/policyplus.aspx
• Published papers
• Cowley S, Whittaker K, Malone M, Donetto S, Grigulis A & Maben J (2014) Why health visiting? Examining the potential public health
benefits from health visiting practice within a universal service: a narrative review of the literature. International Journal of Nursing
Studies (online/early view) http://authors.elsevier.com/sd/article/S0020748914001990
• Donetto S & Maben J (2014) ‘These places are like a godsend’: a qualitative analysis of parents’ experiences of health visiting outside
the home and of children’s centres services Health Expectations (online/earlyview) doi: 10.1111/hex.12226
http://www.kcl.ac.uk/nursing/research/nnru/publications/index.aspx

36. References
• Audit Commission (2010) Giving Children a Healthy Start London: Audit Commission
• Bronfenbrenner U. Ecology of the family as a context for human development: Research perspectives.
Developmental Psychology 1986. 22: 6, 723-742.
• Barlow J., Davis H., McIntosh E., Jarrett P., Mockford C., & Stewart-Brown S. (2007) Role of home visiting in improving parenting and health in families
at risk of abuse and neglect: results of a multicentre randomised controlled trial and economic evaluation. Archives of Disease in Childhood 92, 229-233.
• Brugha TS, Morrell CJ, Slade P & Walters SJ (2010). Universal prevention of depression in women postnatally: cluster randomized trial evidence in
primary care. Psychological Medicine, 41: 739-748
• Christie J, Bunting B (2011) The effect of health visitors’ postpartum home visit frequency on first-time mothers: Cluster randomised trial. International
Journal of Nursing Studies 48: 689–702
• Cowley S (2007). A funding model for health visiting: baseline requirements – part 1. Community Practitioner. 80 (11): 18-24;
Impact and implementation – part 2. Community Practitioner. 80(12): 24-31
• Cowley S and Bidmead C (2009) Controversial questions: what is the right size for a health visiting caseload? Comm Practitioner, 82 (6): 9-23
• Davis H., Dusoir T., Papadopoulou K.et al. (2005) Child and Family Outcomes of the European Early Promotion Project. International Journal of Mental
Health Promotion 7, 63-81.
• Kemp L, Harris E, McMahon C, Matthey S, Vimpani G, Anderson T, Schmied V, Aslam H, Zapart S. (2011) Child and family outcomes of a long-term nurse home
visitation program: a randomised controlled trial. Archives of Disease in Childhood 96:533-540.
• Rose G (2008) (2nd edition with commentary by Khaw KT and Marmot M) Rose’s Strategy of Preventive Medicine. Oxford University Press
• Marmot, M., Allen, J., Goldblatt, P., Boyce, T., McNeish, D., Grady, M., et al. (2010) Fair society, healthy lives: The Marmot Review - Strategic review of
health inequalities in England post-2010. London: The Marmot Review
• Morrell CJ, Warner R, Slade P, Dixon S, Walters S, Paley G, Brugha T (2009). Psychological interventions for postnatal depression : cluster randomised
trial and economic evaluation. The PONDER trial. Health Technology Assessment 13, 1–176.
• Shonkoff JP (2014) Changing the Narrative for Early Childhood Investment JAMA Pediatrica. 168(2):105-106.
• Social Exclusion Task Force (2007) Think Family: analysis from ‘families at risk’ review. London, Cabinet Office
• Sonuga-Barke EJ, Daley D, Thompson M, et al (2001) Parent-based therapies for preschool attention-deficit/hyperactivity disorder: A randomized
controlled trial with a community sample. Journal of the American Academy of Child & Adolescent Psychiatry 40(4): 402-408.
• Wiggins M, Oakley A, Roberts I, Turner H, Rajan L, Austerberry H, Mujica R, Mugford M, Barker M (2005) Postnatal support for mothers
living in disadvantaged inner city areas: a randomised controlled trial. Journal of Epidemiology and Community Health. 59: 288-295
•