Community Practitioners' and Health Visitors' Association

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CPHVA Response to the Review of the Public Health Contribution of Nurses, Midwives and Health Visitors


There is emerging diversity between LHCC’s. This may be expected, as these entities should shape in response to the communities they serve. However, fragmentation without any obvious linkage will have a detrimental effect on progress and may produce ‘silos’. However, LHCC’s tend to be dominated by GP’s whose interest in public health varies considerably. If the ethos of community development is to inform practice then this balance of ‘power’ must be addressed. Therefore, it is essential that the public health role has a clear place within these new structures and within LHCC’s and PCT’s, so that this ethos follows all stands of policy formulation and service delivery. Clearly clinical managed networks or a supported public health network centrally would be an advantage. A Public Health Nurse Co-ordinator (PHNC) is viewed positively, however as there already are Lead Nurses in post there would need to be clarity about their purpose and specific role in order to prevent duplication of duties. It is hoped that the PHNC would not become yet another layer of beaurocracy with a view that this post must be ‘close to the ground’ to ensure more than a superficial knowledge. This would maintain the critical individual knowledge about families, from health visitors and other community practitioner links with the team, and allow a broader, strategic population overview. Perhaps these ‘PHNC’ links could be tiered at operational and strategic levels.

The competencies for the PHNC must ensure that these individuals can lead/ facilitate health within LHCC’s and are ‘fit for purpose’. The CPHVA feels strongly that individuals who undertake these roles have primary care/ public health qualifications and experience, in addition to organisational development and change management skills to utilise existing resources more effectively/ laterally. This must be combined with an ability to understand the roles and contributions of all stakeholders, with impartiality towards individual teams. Power seems to be linked with money, perhaps consideration of a different way of allocating budget, with a proportion to the PHNC as this may help GP’s take the role more seriously.

The current climate of joint planning/ working between social services, local authorities, voluntary organisations, the public and health services will require the PHNC to be prepared to be sensitive to collaborative working, demonstrate an ability to provide links and encourage joint working. LHCCs could be encouraged to develop Community Development Portfolios, which would be informed by LHCC Primary Care Teams working together. Such an exercise would include contributions from other statutory and non-statutory, voluntary and community groups to give a broad view of the populations needs.

The advent of the Nursing, Midwifery Development Unit potentially provides a basis for networking primary care practice/ public health initiatives.

Currently there is little or no perceived link between practitioners/ LHCC’s and Health Boards. Local partnership arrangements are not always effective and mechanisms for practitioners to feed into or be engaged in the HIP/ TIP process are ambiguous or non-existent. It is vital that channels of communication and the principles of a partnership working ethos are further endorsed centrally. Access to funding and funding streams need to be simplified, and transparent to all levels within the service.

There is a prevailing theme that management attitudes are often counter-productive in the development of the public health role or innovation emerged. As an organisation, we would welcome the introduction of management competencies in determining potential ability for undertaking such a pivotal role.

Public Health activity must be given a higher profile within the Trust rather than being a marginal or maverick activity. It should no longer be the case that such activity succeeds due to the tenacity and perseverance of individuals. Greater emphasis should be awarded within Trusts of the need for inter-agency consultation and information exchange. This must be actively demonstrated through joint working initiatives and planning, e.g. local authorities, health representatives on local Trust Boards and health representation on local authority equivalents. Local Health Forum associated to local communities involving stakeholders and the community in planning, perhaps having budgetary powers within the LHCC. The notion of shared authority with the public is not universally apparent within primary care. There is a need for systems of sharing and practices that builds community capacity. Community practitioners should be working with communities to determine their own destiny, however, this requires investment in pragmatic measures to support development activity, e.g. access to transport, mobile crèches.

Community practitioners feel strongly that they wish to be involved in community development work. However, a recurrent barrier in several areas seems to be LHCC’s who are not representative of communities and that outreach work was not supported by current GP attachment (or Trust structures). That is GP practices are bases for their community nurses but the practices have patients scattered throughout the district and individuals in the same family often having different GPs. This leads to fragmented care, duplication and contra-indicates efficient community approaches. The principle of geographical zoning must be endorsed centrally.

There is broad consensus that community practitioners need to be based or accessible to the communities they aim to serve and consequently this will mean being based in alternate locations, e.g. community centres, family centres, refuges, health shops.

This may require a contingency plan for the transition process from a traditional HV role to a ‘new’ population role. Perhaps independent individuals who could begin the process of change could facilitate this; assisting teams to examine and understand each other’s contribution/ role as applied to population need, moving between LHCC’s. Established health visitors indicated a desire to develop community development/ education skills and indicated a need for systematic professional supervision. It is likely that culture of role protection and a desire to ‘own’ certain aspects of the community or workload will cause tensions. This may be exacerbated if it is perceived that non-health workers are undertaking previously health-dominated arenas.

The public health role/ community focus has been eroded by GP attachment. Health visitors feel that their role now involves, in the main, immunisation clinics and filling computer forms because of child surveillance. Indeed additional training was perceived as less of an issue than time to develop community approaches and the emphasis on clinic based activity.

There was some concern expressed in potential tensions that may arise for HVs working with practice-attached caseloads and the public health role within an LHCC. The corporate caseload was suggested as one possible approach in this instance.

It is essential that Health visitors and other community practitioners are using their skills appropriately. They cannot undertake medically led tasks and public health role, in a similar vein school nurses cannot be expected to undertake routine screening and develop their capacity for public health work. However, must make sure health visitors and other community practitioners are not being under-utilised in terms of their skill base. This may involve the consideration of skill mix with HV undertaking a more co-ordination role. This would maintain the critical individual knowledge about families, from the HV links with the team, but also allow a broader, strategic population overview. This approach lends itself to the concept of the PHNC. A large part of health visiting training has involved health needs assessment; these skills are not being exploited and often go unrecognised by Health Boards and GP practices.

Health Visitors had extreme difficulty in defining their role and core ‘business’. Often this has led to Health Visitors plugging the gaps in service provision. For some practitioners this is perceived as strength, however for many this is regarded as a weakness and there is a call for leadership strategically within the profession. Therefore, which areas should Health visitors target their efforts? Arguably, to the most vulnerable within our society, e.g. infants, young children, elderly, chronic sick, mild mentally ill. It is accepted that there is a requirement to establish risk assessment measures sensitively so that HV services may be targeted without an emerging sense of stigmatization. This does not exclude the opportunity of universal access to the service by the LHCC population but may ensure that HV input is given where it may make the most impact. One approach in response to this may be HV working a clinic based rotation so that a professional is available on site daily.

The issue for staffing levels and resources was raised repeatedly in determining health priorities within primary care, as there was a view that practitioners were often ‘fire-fighting’ and not getting an opportunity to be pro-active. More access to public health information already held within health boards would be advantageous.

An area that provoked considerable anxiety within health visitors was that of child protection. Some felt that these children/ families were still their responsibility even if social services carried the statutory obligation. Others felt that health visitor intervention with these cases should be, e.g. to develop parenting initiatives, lobby for improved children’s facilities within the community and parental support programmes. Clearly, there must be rigorous systems in place to protect societies children and there needs to be definition of the core activity and responsibilities of health visitors in relation to child protection.

Specialist nurses were felt to be best placed outwith practice boundaries but accessible by the primary care team. These specialists would also be able to support each other.

There was a consensus that initiatives such as the Quality Practice Award were positive, but that better networking of the processes/ methods between successful practices would be beneficial to all staff within aspiring practices. There is a strongly held view that GP’s often lack a clear understanding of the roles of community practitioners and that there will be a need to actively target this group specifically following the review. There was broad consensus that a move towards salaried GP status would support community/ public health approaches, moving the emphasis away from counting numbers and targets.

Potential for community practitioners to undertake a supervisory role, coordinating a team utilising skill mix in response to population needs assessment. However, such an approach could only be justified if the purpose was to improve services and not undertaken as a cost cutting exercise. Nursery nurses were identified as being key professional to include in the primary care team, their child development skills being acknowledged as a complementary asset. There was discussion around nursery nurses undertaking child surveillance, with the pre-school assessment being done at 3 years of age, as it was felt this would leave enough time for appropriate remedial action if required prior to starting primary one. Duplication was also noted around the health visitor pre-school assessment and a school nurse primary one assessment and whether this could be streamlined. Consideration was given to the appropriateness of health visitors and school nurses undertaking vision screening with a strong preference emerging for systematic use of orthoptist services instead. Other professionals (SALTS, school nurses), the community and voluntary groups should also be considered in any service developments, e.g. in positive parenting initiatives. The development of liaison between primary and acute care, e.g. pave the way prior to discharge and return into the community.

The requirement for flexibility is recognised, encouraging approaches that may be tailored to ‘fit’ population need in conjunction with a service requirements, e.g. caseload planning. This is particularly significant in rural and remote areas with double/ triple duty staff. However, organisational structures and renumeration packages do not support flexible working approaches within primary care. The aspect of safety for professionals working within the community setting must be addressed, as practitioners feel vulnerable and at risk often.

How will contribution of community practitioners to the public health agenda be measured, as obviously the outcome of their interventions may not become visible for 5-10 years? There must be a shift, to include ‘softer’, qualitative, indicators, to augment the favored approach of ‘hard’ quantitative indicators of a purely medical model.

There was some concern regarding the area of triple duties when it came to health promotion, in as much that when demand for competing resources was high, often the prevention and promotion aspects were marginalised in favour of treatment and cure.

The CPHVA encourages consideration of joint training opportunities at various times within the career pathway. This should include differing disciplines who work within the community, e.g. teachers, police, social work, medical.

The contributions of health visitors and school nurses were viewed as broadly similar. There is real potential for development of the public health role within the school population to meet the health needs of school children. However, school nurses appeared to be in a similar position to that of practice nurses, several years ago, in terms of a lack of systematic training and disparity in working practice/ remuneration.

School nurses are in a good position to develop public health programmes within primary and secondary education, e.g. Healthy Lifestyles: A school, population focus that aims to instill health habits at an early stage of life which evidence suggests will have a long-term impact on adult life, Mental Health: This presents a key area for school nurses to intervene to limit damage by undertaking 1st tier work supporting children awaiting assessment or to work with 1st tier children who do not need 2nd tier intervention. It is essential that school nurses are given appropriate training and are linked to psychologists to undertake this preventative and supportive role, Chronic & Complex Health Needs: These children, their school carers and their teachers need support and training to create the best environment for special children. This offers a crucial role for school nurses. They should not be regarded as the hands on care givers in this instance, but have a pivotal role in developing proactive, appropriate training, policies and communications to ensure the child can maximise the advantages, Vulnerable Children & Young People: This embraces the Social Inclusion policy agendas and includes children who are looked after, high risk, homeless family accommodation and child protection.

There is much debate about how the school nursing service should be structured and where does this service fit within the new NHS. Strong opinion was voiced that current structures do not facilitate joint working i.e. school nurses employed within acute trusts. In addition, consideration that school nurses could be linked to LHCC teams to ensure broader scope and greater public health continuum.

Historically there has been no career structure for school nursing. There should be different pathways for career progression especially if the intention is to build up teams of skills that are complimentary.

The CPHVA would welcome a national review of record keeping systems and the principle of standardisation within Scotland of needs assessment/ recording. There is a view that parent held records are not generally successful as not every profession was committed to the concept resulting in incomplete records. Shared notes and documentation is seen to be an advantage between various disciplines and departments. The advent of IT and paperless practices with regard to this is regarded as a great opportunity to streamlining care and managing risk. A single shared record was considered positive, particularly in monitoring mobile, vulnerable families and there was a view that confidential information could reasonably be shared between health, social and education agencies. Firewalling techniques would be required for all electronically held records and there was some concern over how data would be archived.

It is recognised that community practitioners need to apply evidence where it exists and to contribute to an evidence base within primary care. However, this requires support to ensure rigorous methodology and techniques to develop a competent working knowledge. This should be assisted with NRIS, Nursing, Midwifery & HV Development Unit. Universities and other relevant organisations should have a contractual obligation to the public health agenda, with increasing dialogue between academic departments and service.

However, community practitioners have an obligation to build on existing evidence bases within primary care, which are outcome based not on activity measurement. This will require education & training, and a support infrastructure to support rigorous research activity and cross-fertilisation of ideas/ work.

Public health strategy must embrace the elements of Promotion, Prevention, Protection and Proof. Education and training is key. Requirement in undergraduate programmes to focus on health not illness is applauded, however, perhaps this programme is attempting to be too ambitious as the medical model may be more easily identified with by 1st level students Also, practice placements are more likely to endorse illness within the NHS.

This requires recognition of community as a specialist branch and the post-basic training should reflect this. Recognition of this specialism will also require investment in preceptorship programmes and scrutiny of the preparation and remuneration of community supervisors.

However, there also may be a need to re-educate established health visitors who may have lost community development skills because of internal market approaches. Leadership programmes are lacking, where practitioners may learn management skills including negotiation, facilitation, managing change, corporate language. Consideration should be given to incremental levels of learning perhaps through open learning programmes or day release, which would be potentially accessible to the entire workforce. Techniques, e.g. Business Process Mapping should be rolled out throughout all levels of staff, in an attempt to encourage critical review of operational activity at all levels.

Shadowing opportunities for community practitioners to follow the work of public health departments, or secondments into other working areas, e.g. community development

There is also a need to give devolved decision making powers as part of an autonomous process, to make some decisions at a ‘lower’ level in the hierarchy, so that the service is more responsive and to develop practitioner skills.

Professional Officer, CPHVA
August 2000