Glasgow LMC: Health Visitor Review Response

Executive Summary of GP Subcommittee of the Area Medical Committee and Glasgow LMC Response to the Health Visitor Review

· We agree that the focus of health visitor practice within NHSGGC should be health improvement, prevention, early intervention and management of risk using an inequalities sensitive practice approach. However we think this should be clarified to children aged 0-5 and their families.

· We agree with the ‘Priorities for practice’ except that engagement with all families should extend well beyond 10 weeks.

· We recognise and highly value the work of Health Visitors in engaging with families in the early years of their children’s lives. We also value their presence in the Primary Health Care Team.

· We believe that ‘attachment’ to a particular defined group of patients and families along with the wider Primary Health Care Team adds value to the Health Visiting role and strongly assists them in engaging with families.

· We accept that there is a need for Health Visitors not to be exclusive to those patients as caseload within the practice population will vary in volume and complexity over time and there need to be flexibility in the workforce to cope with this variation.

· We agree that there needs to be better professional and administrative support for Health Visitors in their challenging work and we think this can be provided from enhancements to the current CHP arrangements. We also think that administrative and IT support could be cost effectively extended to the Health Visitors through the General Practice to which they are attached.

· We believe that the major structural and cultural re-organisation required to shift to new multi-disciplinary teams (as opposed to the current Primary Health Care teams) represents a waste of organisational and professional time and energy with no reasonable expectation that it will improve outcomes for children and families.

· We believe that Health Visitors need to continue to be in contact with children and families during the first year of life in order to be confident of correctly identifying those children and families who will need ongoing additional support. These contacts would most effectively be at the time of childhood vaccination.

· We believe that Health Visitors participating in the vaccination of children enhances their relationship with families, provides an opportunity for assessment and intervention as appropriate to that child and family, and supports high levels of vaccination especially in deprived and disadvantaged communities (as expressed in Hall 4).

· We believe that skill mix already operates in the vaccination clinics and could appropriately be further developed. However, we believe that the Health Visitor should be present at the time of vaccination to meet the parents and child and engage with them as appropriate to their needs.

· We believe that, with greater skill mix, the time spent by Health Visitors at vaccination clinics could be more effectively used to deliver the benefits of their higher level skills to families at these contacts.

· We believe that Health Visitor should continue to hold personal lists, attached to practices but have a geographical alignment to and membership of joint children’s services teams.

· We believe that the Health Board should work with Health Visitor, Public Health and General practitioners to find a shared view of the best way to delivering the Benefits of Health Visiting to children and families in the early important years of the children’s lives.

We had great difficulty in clarifying the process for the review. The Steering Group established in East Renfrewshire had very little grassroots representation on it. When we wrote to ask that a GP from the representative structure be included in the group we were told that a wider reference group (Greater Glasgow & Clyde Review Group) comprising a balanced membership including stakeholders, would be set up. This never happened.

The GP subcommittee had two meetings with the Director of Planning GG&CNHS Board and the Director of East CH(C)P to discuss the review. We still await details about how geographical teams would be constituted.

The briefing sessions given to staff presented a non-negotiable vision of future structure and caused justifiable dismay in the Health Visitor and GP community.

The review of evidence in published and unpublished literature in fact produced no convincing evidence to support the proposed changes, and gave no support to the belief that the changes would improve child health. We have commissioned an academic review of the source documents from Dr Philip Wilson, DPhil MRCP MRCPCH FRCGP, and this forms part of our response at appendix A. Critique of Evidence Base

Glasgow and Clyde has a disproportionally large number of children living in deprivation. This is a fact, and all of us are aware of the problems this brings.

“Hall 4” recommendations regarding 3 tiers of service are clearly understood and appropriate. However in the Hall 4 documentation, there is no suggestion that Health Visitors should be removed from the immunisation process, indeed the reverse is the case. In the Hall 4 recommendations a key part of the core programme is the immunisation schedule, and this is described as an ideal opportunity to engage with all families, to better asses risk and vulnerability.

The concept of closer liaison between Health Visitors and Children’s Teams comprising other agencies is clearly desirable, but must not be pursued to the detriment of existing effective relationships. We shall comment on this later.

Integrated services. We dispute the assertion that “…local experience and evidence from other areas particularly in the field of learning disability, addiction and mental health have demonstrated that the establishment of multi-agency teams of staff working to a defined geographical area significantly improves outcomes for service users.” Integrated teams appear to work best where the cases are complex and the volume is low. However integrated child teams would struggle to deal with high volumes of work. The difficulties and challenges caused by setting up new multi-disciplinary teams are immense. Cultural and administrative differences between the various agencies take years to overcome. Pure ‘corporate working’ can and does disguise staff vacancies and shortages, with consequential falling morale and rising sickness levels. It can and does result in no individual taking responsibility for a particular patient’s care. Individuals having a clear sense of individual responsibility to defined populations can avoid this ‘collusion of anonymity’.

Any major restructuring of services causes stress in staff, some will leave or retire, and huge amounts of time are consumed by the restructuring itself, to the detriment of services to the population. As most of the substantive proposals have no evidence base that they will lead to improvements in care, we consider these proposals to represent an unacceptable risk to the effective delivery of children’s services. GG&CHB should think long and carefully before it imposes another major reorganisation on its staff, and more importantly, on its population.

We agree that we should review this across the city. However it is worth pointing out that there was a previous resource allocation exercise in the 1990s, supported by Professor Jean McIntosh of Caledonian University. This model posited an increase in health visiting resource to deprived areas, with the most deprived area receiving twice the health visitor resource of the least deprived area. The Board attempted to achieve a considerable redistribution according to these principles over a 3 year period, and we believe this was more or less achieved, but with significant difficulty and turbulence. Any further redistribution should take account of lessons learned during this earlier exercise. Practices in relatively “under deprived” areas must still have sufficient health visitor resource to provide a safe and credible service.

Unfortunately, the evidence presented on the website does not support the move to geographical areas and skill mix, please see appendix A. The proposals are based on the concept that “the principle seemed sound,” not on any actual evidence of effectiveness.

We agree with all of these headline statements, with the exception of no.6 regarding geographical arrangements.

There is discussion that current early assessment processes are not sensitive enough to identify risk. We would agree. Indeed the Board’s own review of “Starting Well” showed that assessment of children prior to 13 weeks of age, only placed 50% of them correctly in the vulnerable category. This was a well funded project with dedicated health visitors with small caseloads, and yet it took at least to 39 weeks to assess the vulnerability of children and institute appropriate support. Even if the child was correctly assigned at the ten weeks, family circumstances can change and the child may become at risk

There is mention of specialist health visitors working with asylum seekers, homelessness and child development centers and that this “..reflects a difficulty in releasing health visitor time from providing universal and practice based services to focusing on particular groups or geographical areas..” However we do not see how the proposals in the review will remove the need for these specialist teams.

There is discussion of child protection. If health visitors are removed from contact with all the core families at a very early age, their ability to identify children at risk will diminish and they will be less rather than more effective in this role. We understand and sympathise with the Board’s desire to prevent the tragedies of child death or serious injury in the domestic setting. No-one could deny that everything that can be done, should be done, to prevent these terrible incidents. We realise (although it is not explicitly stated) that this is a major driver for reorganisation. However we must reiterate that no evidence has been presented that shows that the proposals in the review document will deliver this outcome.

We very much agree that health visitors should have good I.T. and support structures, and shall comment on this in more detail later.

We understand that the number of staff involved in this activity is quite small. They provide a valuable service and the Board should seek to re-provide these services in a cost effective manner via adult services. Elderly people also appreciate the continuity currently available from a named nurse. We do agree that health visitors should be refocused on children’s services.

This section starts “The current arrangements for immunisation have been extremely successful with consistently high achievement of rates even in the most deprived and hard to reach communities. This demonstrates that delivery in the setting of general practice is highly effective”. We agree. Childhood immunisation targets are consistently met in Glasgow, and we believe that the combination of practice support and location, the skills of the health visitor, and the continuity provided by this team is the reason for this success.

In the last 15 years in Glasgow, the participation in immunisation by health visitors has been actively promoted by the Board, to the benefit of the population. Had this not been the case, practices would have sought and received additional funding to undertake this work themselves. Such funding for the staff time would then have been included in the Global Sum received by practices. The current resource of Health Visitor time spent on vaccinations should be considered to be “an existing funding stream” under the nGMS Contract. We hope that the immunisation rate would have been as good, but the participation of the health visitor brings added value to the system that cannot be measured by simply looking at immunisation rates.

The document states “Giving the immunisation injections does not require the specialist skills and training of a health visitor.”. This suggests that the giving of the injection is a simple mechanistic task. It is not. The educational resource group for Health Protection Scotland promotes training for childhood immunisation that is comprehensive, challenging and assessed as being at degree level. Health Protection Scotland recommends that everyone involved in providing or facilitating immunisation, should have undertaken this training, so that they understand the programme, the scientific foundation of immunisation, and can answer the many complex questions parents have about the schedule. The immunisation schedule itself is now at a level of complexity that is quite daunting, requires in depth knowledge, and more importantly, a continuity of care so that the individual assessing, counselling and informing the parents should also preferably be the person giving, or at least present at the immunisation itself. Continuity and consistency is vital to prevent medication errors that can occur if the immuniser is not familiar with either the practice or the child.

The immunisation process itself affords a good opportunity for a health visitor to see parents and their children in potentially stressful conditions and identify additional needs that require support. It is an occasion when opportunistic intervention and access can be achieved, potentially preventing damage and risk to child and family. Health Visitor involvement in these important events helps to establish an ongoing relationship with the family. This helps the Health Visitor to be seen as a Health Care worker (a role which is recognised as having more positive associations than other child support workers) which makes it easier for the family to ask for or receive help.

It is suggested that health visitors currently spend a “a substantial proportion of their time engaged in immunisation”. For an average practice this might represent 10% of their time. We don’t think that this is a “substantial” proportion; and it is certainly not disproportionate to the value of the work undertaken.

The review suggests that school nurses should not provide immunisation. We cannot believe that immunisation rates for school children would attain anything like the levels that they currently do if this activity were removed from schools, and are puzzled as to what proposals in this respect would be.

We agree that the variation in resource in relation to need should be revisited, with the proviso that lessons are learned from the previous exercise in redistribution, and that every practice must have sufficient health visitor resource to provide a safe and credible service.

The GP attachment model does indeed lay bare the problem caused by staff sickness etc. However the development of geographical teams would doubtless be expected to cover and hide such deficiencies by all members of the team having to work harder. We shall discuss this in more detail later.

The document states “The links with general practice in supporting children and families as part of both universal and targeted programmes are highly valued both by health visitors and the general practice team.” We agree.

The document also states that other agencies that may be involved in child care are geographically based and therefore linkages will be required to several teams. If health visitors are reorganised into geographical teams, this will destroy an interface that everyone acknowledges works well, and substitute an interface that is unproven, with no evidence that it works to deliver benefit. However, we do agree that health visitors and practices should have stronger linkages with other agencies. The current geographical services such as education and social work should also form stronger linkages with each other, as well as health related agencies. As there seems no actual possibility that all agencies be physically co-located, the description “team” should perhaps be replaced by “network”. However this is not a cheap option. Efficiencies that might be realised by joint planning and elimination of duplication will be swallowed up by the time required to communicate effectively with all “team” members. If this time cost is not factored into new arrangements, all the supposed benefits will be lost.

We agree that health visitors require clear support and management. We do not see why this cannot be achieved by enhancements within the existing CH(C)P structure. GP practices would like to be acknowledged as part of that support structure.

· The focus of health visitor practice within NHSGGC should be health improvement, prevention, early intervention and management of risk using inequalities sensitive practice approach for children aged 0-19 and their families.

We agree with the basic sentiment but would point out that health visitors could not be involved in the full 0-19 age group. Their primary focus should be the pre-school child, with some capacity to extend their remit to older children especially if they are involved with other children in the family. With this clarification this recommendation is not contentious.

· Engagement with all families up to 8-10 weeks to provide comprehensive assessment to identify the appropriate level of support required

· Effective Liaison with midwives providing antenatal and early postnatal support

· Provision of a core programme to all children and families

· Provision of additional and intensive support to those who require it, working with other agencies

Health visitors must have the capacity to engage with all families beyond the 10 week mark, in order that they can safely identify need and risk. The situation of a child is not fixed at 10 weeks, and new needs and risks can develop over time. We suggest that an effective way of maintaining contact is to continue to participate in the immunisation schedule of contacts

· Assessing risk and safeguarding children

· Supporting parenting capacity via parent support and education programmes, improving literacy and promoting social inclusion

· Working with parents who have alcohol and/or drug misuse problems to support their parenting role and to work with other services to manage their addiction.

· Improve response for and support survivors of gender based violence

· Tackling key health improvement priorities in particular reducing obesity, nutrition, physical activity, increasing breastfeeding rates, smoking, alcohol, drugs, injury prevention and oral health

· Promoting infant, child and parental mental health

We believe that the first four bullet points relate to work that might be undertaken by health visitors, but much of it would be seen as a social work function This document continually states that health visitors should focus their work in their area of training and experience, and we are concerned that these proposals will actually divert them from their areas of strength. The Health Visitors skills should be focussed primarily on health improvement as per the last two bullet points.

· Leading on assessment, building relationships and making decisions regarding health plan indicators with all families and continuing to provide services for those in additional or intensive groups

· Assessing the impact of different forms of inequality and defining the appropriate response in light of this

· Managing risk and decision making in conditions of uncertainty

· Identifying and addressing difficult issues with families

· Providing professional supervision and appropriate delegation for skill mix team members

· Building relationships with and working as part of the integrated children’s services teams and primary care based services

· Contribute to the delivery of the health protection service locally

· Contribute to the development and delivery of child and family health improvement across a range of settings including home, community and school

We agree that non-child workload should be identified and provided in some other appropriate way by adult community services, and that consideration should be given to the merits of continuity and trust that older people also cherish from a regular visitor.

· Health Visitors should no longer be involved in giving immunisation injections in practices. A clear transition plan will be developed to move from current arrangements without impacting on immunisation rates.

· The skill mix within teams should be developed to reflect the local needs profile to provide the universal service and support the targeted service

· Appropriate management, administrative and IT support should be available to support teams

· School nurses should work as part of a team with health visitors to provide co-ordinated support to families

We do not agree that health visitors should no longer be involved in giving immunisations. We believe their participation is a major reason for good immunisation rates. However, if a community team is providing the immunisation, the team could perhaps comprise a staff nurse and a health visitor; the nurse conducting the practical procedure and the health visitor engaging professionally with the parents, counselling and observing and enabling opportunistic health promotion intervention.

Skills mix should be considered carefully. A key strength of the health visiting service is continuity and trust. Much can be lost if too many healthcare professionals interact with a family. The published literature indicates better outcomes with properly trained specialist health visitors.

Practices would welcome the opportunity to be involved in providing administrative support to health visitors. We believe that this might prove more cost effective than setting up a whole new system. The current IPACC exercise, which aims to provide an integrated IT system to primary care, will make this a simpler option. Current scoping at Scottish Government level indicates that GP and community staff common systems can be achieved easily; there is more doubt about true integration of community nursing and children’s services, and true integration with social work systems remains a difficult and distant concept.

We agree that school nurses should work with health visitors, and thought they already did so. We should point out that school nurses currently work with all the children in a school, who may be outwith geographical zones, just as practice patients may be.

· Health visitors should be part of integrated and joint children’s service team arrangements, with a geographical rather than practice focus.

· Health visitors should be supported by being part of a team with a skill mix including current health visitors and school nurses, nursery nurses, support workers and others.

· The team should be based where possible with other children’s services in a joint community base

· Health visitors should be aligned to general practices and groups of schools. Contact and referral arrangements should be clearly defined and monitored

On the contrary, we suggest that health visitors have a practice focus and a geographical alignment. This should address the requirement for interacting with other agencies for their complex cases, and retain the proven benefits of the current system.

We suggest that skill mix be looked at very carefully and implemented in a measured fashion to ensure that the benefits of the personal trusting relationship and the assessment skills of the health visitor are not lost.

We do not believe that co-location with all other children’s services in an actual building is achievable. It would require major disruption of existing teams and premises in social work, education, mental and physical health and addictions. This view has been reached after discussion with Board and CHP officers.

We have real concerns regarding confidentiality in a multi-agency team. Although the protection of children overrides many other duties, we believe that low level concerns would not be readily shared with a health visitor if it was known that all members of the “team” would have access to it.

We believe an identified shared building would represent a barrier to families, who would perceive a stigma related to accessing such services. By contrast, accessing health visitor services in a surgery setting is normal, non-threatening and socially acceptable.

We have had experience of social workers attached to practices, and believe this to be a superior system for integration, personal responsibility and access.

We believe that the concept of a robust network comprising these agencies is more achievable and may possibly deliver benefits without the inevitable distress and dislocation engendered by major organisational changes.

Health visitors should continue to be attached. However there is merit in discussing a small team approach e.g. two or three health visitors having a close relationship with a practice, thus assisting with arrangements during holidays etc. Any larger number risks destroying the current benefits and rapid informal communications. Larger teams can also disguise staff shortages and create stress and dysfunction in the team. The pilot scheme of corporate working in Drumchapel identified staff shortage as a major problem in the functioning of the team. The corporate model was not continued. The practice health visitor(s) should attend relevant practice meetings and be easily accessible at other times. Any purely paper/electronic referral system would destroy the efficiency of current responses. We do understand that children resident outwith the relevant CHCP and also geographically distant from the Health Visitors’ base, represent a challenge for service delivery. However we believe that sensible cross cover arrangements could be made for the small number of families who fall into this category and who also require frequent home visiting, without compromising practice attachment.

· Health visitors should work as part of a team to enable flexibility to respond to fluctuations in workload and staff absence

· Robust arrangements for team leadership, management and professional supervision need to be in place. This may vary in line with local CH(C)P structures.

· Regular Child protection and complex case supervision is needed for all team members

· A regular audit cycle should be in place to monitor performance of teams

· Clear protocols and service descriptors should be developed

· A competency based approach to practice should be developed

· A learning and development framework is needed based on current evidence and priorities for practice

These points relate to professional and managerial matters. However, we would stress that we are anxious to be involved in supporting our much valued Health Visitors in every way we can, be it administrative or IT support, or professional and personal support in their difficult and challenging job.

This is unfortunately one of the most disappointing parts of the whole document. We have been repeatedly assured that the document is for discussion, that it is not a final proposal, and that all views are welcome to inform future work.

This section, however, suggests that the proposals are set in stone, and indeed already being implemented. We sincerely hope this is not the case and that our response to the document will be acknowledged, and that we can work together to achieve improvements in child health and safety.