Community Practitioners' and Health Visitors' Association

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CPHVA Response to the National Service Framework for Children, Young People and Maternity Services

The CPHVA welcomes the publication of the National Service Framework for Children, Young People and Maternity Services. We endorse the principles of this ten-year plan that put the needs of children and families at its core. We are particularly pleased by the recognition of the need for early intervention and the focus on special groups of children such as those with special needs. Partnership working, reducing inequalities, prevention and health promotion and child-centred services are key and necessary themes throughout the document. These are the principles that the CPHVA has long advocated as central to providing the kind of service that is required to fully meet the needs of the nationís children and families.

In particular the CPHVA welcomes the proposals to improve long term health outcomes of poor health in childhood. Health visitors and school nurses will no doubt want to fully support the many recommendations around the needs for early intervention and primary prevention for all children which most are currently trying to achieve with inadequate resources. There is clearly a need for a significant increase in the numbers of both professional groups to achieve this aim.

Despite the obvious need for more resources to achieve the NSF guidance there is no mention of ring fencing of new monies to support the call by Professor Al Aynsley-Green, the NSF Chair, for extra investment for training and supporting nurses (Aynsley-Green, 2004). It seems it will be up to local Trusts to decide how and when within the ten-year period they will implement the guidance. The CPHVA calls upon the Department of Health to be more specific in giving guidance to Trusts in improving standards of children services and more importantly to ring fence the money needed to ensure that the guidance will be translated into action.

The CPHVA, whilst welcoming the overall vision of improving services to children and families, has a number of serious concerns regarding key aspects of section three of the document relating to maternity services, which we consider will be counterproductive to the core recommendations.

We are particularly disappointed in the lack of any real recognition in this section of the health visitor role postnatally. Their role currently involves meeting the needs of the whole family including the child and the mother in the postnatal period with a specific focus on the promotion of positive health. The document recommends that mothers should in the future be visited by the midwife for one month post delivery and for up to three months if the need exists.

The CPHVA would like to question how the necessary funding would be raised for this new proposal to extend the role of midwives. It seems completely inappropriate that midwives, who are already struggling with resource challenges in delivering the necessary antenatal and postnatal care, should now be asked to extend their service further into the postnatal period, particularly as there are qualified, competent health visitors already carrying out this professional role albeit with inadequate resources.

The health needs of families in this early postnatal period can clearly be adequately met by health visitors provided they have sufficient numbers to do so. Health visitors have a broad range of expertise, all are registered nurses, whilst many have also either trained as mental health nurses, midwives or done a course in obstetric nursing. They also hold a post registration specialist qualification in public health / health visiting which includes training around child development, child protection, domestic violence and postnatal depression, and many have developed specialist expertise in these areas. Health visitors would welcome the opportunity to provide more support to mothers at this time, but unfortunately current resources dictate otherwise.

The Acheson Report (DoH,1998) identified health visitors as the key workers providing services to mothers and babies and that evidence supported the importance of this early intervention to outcomes in later life. The CPHVA is critical that the recommendation made in the Acheson Report to expand health-visiting services is the only recommendation that has not been taken on board and incorporated into policy.

The CPHVA believes that significant improvements can be made to services for families and children without major changes to professional roles, if communication between midwives and health visitors is improved and joint working is encouraged. In many areas midwives and health visitors already work closely together, providing family centred care according to the specific needs of the family members. In this way the skills and expertise of the professionals can be utilised appropriately, and contact with the family can be negotiated according to need without following rigid guidelines. We would therefore recommend training and development to enable closer working relationships between midwives and health visitors across the UK rather than major changes to professional roles.

In contrast to the recommendation for the extended role of midwifery, the CPHVA strongly recommends, in line with the core standard page 36, that health visitor input starts in the antenatal stage. This is also indicated by a growing research base for example, An Equal Start (IPPR 2003), and is highlighted in the Health Visitor Practice Development Resource Pack (DoH 2001). This would enable her to carry out an initial comprehensive assessment of the familyís needs and to help build a rapport with the mother at this time when it is generally accepted that she is more likely to be amenable to health promotion. The relationship built at this time is fundamental to the ongoing role health visitors play in supporting families right through the life of the child until school entry and beyond.
In fact there are major implications in terms of resources and training should the midwife continue to visit up to three months unless this is alongside the health visitor. For example the current direct entry programme to midwifery would have to be extended to cover in detail child development, counselling, child protection, health promotion to name but a few of the skills that health visitors require to provide their current service. The average age of a health visitor is currently mid to late forties. This enables her to bring to her role a lot of life experience as well as her nursing and other professional qualifications. Compare that to a direct entry midwife who realistically may be much younger given that student midwives accessing this course can do so at age seventeen and as such may have very limited life experience. She will frequently have to contend with complex family problems ranging from child sexual abuse, domestic violence, neglect, substance misuse, behavioural problems, mental health disorders and a wide range of physical ill-health whilst working autonomously in homes within the community.

Under the current requirements for midwifery pre-registration training, these and a myriad of other key components of health visiting practice are either insufficiently covered or not included at all. Far from reducing inequalities and improving services to families this move could, in our opinion, lead to a more fragmented approach to service delivery and as such have a detrimental impact on the lives of children and families.

How will service commissioners interpret the recommendation to extend the role of midwifery up to three months in the postnatal period? There is little doubt that it could be seen by many as an easy option to cut back even further on health visitor input. This would further reduce the potential input of the health visiting service in promoting positive mental health in conflict with earlier recommendations in this NSF.

It is clear from the recommendations that there has been little or no consultation with health visitors in developing the section on Maternity services, even though if implemented it has the potential to have a major impact on the future role of health visitors. The feedback from minimal consultation, at the latter stages of the NSF development process, with the CPHVA was regrettably ignored. It is very unfortunate that health visiting was not represented on the team of individuals coming from obstetric and midwifery backgrounds who wrote this standard.

We therefore urge those responsible for this document to review the recommendations relating to maternity services. They need to consult with all the stakeholders providing care to mothers and children so that future services will be provided by a range of professionals suitably trained to meet the laudable principles enshrined in this document.

References:

Aynsley-Green A, cited in Hartley J. Childrenís tsar calls for nurses to improve standards of care. Nursing Times 2004; 100; 38, 4.

Acheson D. Independent Inquiry into Inequalities in Health. London; The Stationery Office, 1998.

Department of Health. Health Visitor Practice Development Resource Pack . London; The Stationery Office, 2001.

Harker L, Kendall L. An Equal Start? Improving support during pregnancy and the first twelve months. IPPR 2003.

 

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