Community Practitioners' and Health Visitors' Association

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Recognising the Potential : A review of health visiting and school nursing in Wales - Response by The Community Practitioners and Health Visitors' Association



The CPHVA welcomes the opportunity to comment on the National Assembly for Wales’ ‘Review of Health Visiting and School Health Services in Wales (2000)’.

The evolution of the Community Practitioners and Health Visitors Association is closely linked to the development of public health policy, and we have welcomed and supported the present government’s emphasis on improving the Public’s Health in its policies.

The longstanding existence of health visitors as nurses with a public health focus is evident but it has been, and is very much argued in the Review and supported by our consultation with members, constrained in the last few years by an increasing focus on the ‘medical’ and task aspect of their work .

It is important to note and also to put the Review’s findings into the context of the history of the development of health visiting as a profession and to consider the findings of this Review within the context of that history and the recent history of NHS policy changes.

The Review does this very well and the recommendations also stem from this basic understanding of what the professions of health visiting and school nursing have to offer as public health nurses within the present health policy framework.

The Association itself has been concerned for some time that the contribution of health visitors and school nurses is being constrained by the organisation and structure of the present health service in Wales. This Review both confirms our worst fears but also gives us an opportunity to address issues that would otherwise have remained unresolved with the inevitable consequence of the delay in achieving the Assembly’s ambitious plans for improving the health of the people of Wales.

The Association can confirm the findings of the Review and we generally agree with all the recommendations. Following extensive consultation with our members in Wales and throughout the UK it is obvious that Wales has fallen behind the other countries of the UK in developing the potential of nurses in public health. It is imperative that the recommendations of the Review are seen as the beginning of the process of reducing this gap between the countries, and a great deal of thought and commitment from Assembly level down to practitioner level must be put into the implementation of the recommendations.

The Association feels that it is essential that the Assembly commits substantial resources over the next two or three years to quickly reverse this crisis in public health nursing in Wales.

In England, in order to assist the health visiting and school nurse professions to meet the new public health agenda a £1million Innovation Fund was introduced. Substantial resources from the tobacco tax will be invested in public health nursing in Scotland and in Northern Ireland a recent study recommended the possibility of creating specialist public health nursing posts to take the agenda forward there.

We are satisfied with the scope and purpose of the Review and although it would have been very useful to find out the views of Local Health Groups, we appreciate why they were not included in this specific review. CPHVA members who are members of LHG Boards have given their views of the Review and these are included in our response.

It is extremely worrying, but not surprising, that some of our members have expressed their belief that the situation described in the Review may only be ‘the tip of the iceberg’ and the situation may be worse than the focus group findings suggest.

It has been suggested that the findings of this Review and its recommendations be included in the Assembly’s Primary Care Strategy. We agree that the Primary Care Strategy should consider and be seen to be acting upon the findings of this Review. However, this Review has identified a serious policy / practice gap which has implications not only for Primary Care in its narrow and wider definitions but for the Health and Social Care services in general and needs a comprehensive debate, discussion, and strategy of its own.

An Action Plan for Public Health and Public Health Nursing in Wales

We feel that the current issues identified in this Review warrant the drawing up by the Assembly of an urgent action plan.

Without a concrete plan of action with targets that can be measured; an overview of the different components that influence the direction of public health nursing; strong leadership from the Assembly and reporting and evaluation of progress at the highest level in Wales, we will return to an even more bleak review in another ten years.

We note that in the English National Plan for the NHS, in the section ‘Priority Guidance, the expected outcomes include:

" To help narrow the health gap in childhood – and throughout life – between socio-economic groups and between the most deprived areas and the rest of the country....."

The section covers a wide range of health issues (disability, chronic illness, education, mental health, youth offending, adoption etc) with targets for services to be developed in early 2001.

We would hope that such priorities and expected outcomes will be targets for the NHS in Wales. We believe that any such targets and outcomes will be very difficult to achieve if the concerns and recommendations of the Review are not acted upon.

Action and commitment at Assembly level by both politicians and civil servants is absolutely necessary to facilitate the integration of the public health agenda into the health service by the development of strong public health nursing leadership.

At the second WHO Ministerial Conference on Nursing and Midwifery in Europe (Munich, June 2000) Ministers of Health of Member States in Europe Region of the WHO stated:

We believe that nurses and midwives have key and increasingly important roles to play in society’s efforts to tackle the public health challenges of our time, as well as in ensuring the provision of high quality, accessible, equitable, efficient and sensitive health services which ensure continuity of care and address people’s rights and changing need."

Although the Secretary for Health and Social Services in Wales is not a member state Minister for Health, we believe that the Secretary would be in full agreement with this declaration and would wish to support the development of high quality health visiting and school nursing services in Wales.

Leadership in nursing should first and foremost come, as it does, from the Chief Nurse in Wales. Again, in the European context, an initiative to strengthen the nursing contribution to public health outlines the action that CNO’s should undertake to develop further the nursing contribution to public health. It is recommended that all member states within their own country should, amongst other recommendations,

  • agree strategically the nursing contribution to public health

  • ensure that the CNO of each country analyses the public health agenda and puts in place action plans to deliver the nursing contribution,

  • ensure that CNO’s consider how to provide and stimulate leadership in the nursing profession in relation to the public health agenda in their own country.

However the pressure on the small staff at the Nursing Division seems to be enormous and it is virtually impossible for this task to be done with the existing establishment.

There are so many public health policies developed in the various Assembly departments that would be much more rounded policies were they to have a public health nursing input. Consequently, in the field of public health policy development, the wheel is being constantly and wastefully reinvented.

The Association strongly believes that the Assembly needs at least an increase to a full time equivalent public health nurse post.

This Assembly level public health nurse we envisage would, under the direction and leadership of the CNO in Wales and in partnership with others, lead a ‘trouble shooting team’ that could assist the service in putting into practice the agreed recommendations of the Review as well as the wider Welsh, UK and European aspirations for public health nursing.

This team should consider the findings of the Review and agree the strategic contribution of nurses to public health in Wales. It should consider and develop, in collaboration with the service and partners, action plans at Health Authority and Trust level for the implementation of specific recommendations and be expected to assist in the implementing and evaluating the plans.

We believe the first step before commencing on a rescue plan is for all Trusts in Wales to agree to the following recommendation and that they should be encouraged by the Assembly as a matter of public health and protection to do so.

We recommend that Trusts examine their management arrangements for the health visiting service to ensure effective professional leadership and support for front line staff; the arrangements should include a designated head of health visiting service.

Better Health Better Wales and the Strategic Framework refers to this Review as to " identify service needs and to produce recommendations for service and developing roles and responsibilities to support children and their families"

There are many policy opportunities for health visitors and trained school nurses to use their expertise both within the health service but equally important by becoming fully involved in all the other policy initiatives that impact on children and their families.

The service clearly needs assistance to free their public health nurses to participate in these initiatives.

Some of the innovative practice identified by members from other parts of the UK can be found in Wales, but the present information gathering systems do not allow them to be demonstrated and their value within the Health Service goes unrecognised:

  • Health Action Zone funded post natal depression support groups, run jointly by health visitors and community psychiatric nurses. The groups run soft play centres with crèche workers to look after the children.

  • Health visitors and school nurses looking after the health needs of young offenders within Youth Offending Teams

  • Research posts for health visitors within a Sure Start funded area looking at post natal depression in an area with a high ethnic minority population

  • Outreach health visitors and school nurses working with prisoners and their families focusing on the mental and emotional health of their families.

It is obvious that there is little understanding within the Health Service in Wales of the health visitor’s role and the potential of the school nurses role.

We therefore fully agree with the following recommendation as the model of health care that Wales should adopt without reservation. This model would provide the ideal environment in which public health nursing could flourish and fulfil its potential.

We recommend that Wales should adopt the targets and strategies set out by the World Health Organisation in Health 21 and use it as a framework for its own action plan.

Education and Training of Public Health Nurses.

We recommend that for health visitors the length of the course should be extended from the current minimum of 32 weeks to at least the previous minimum of 51 weeks, within which a ten-week period of supervised practice should be reinstated. Part-time options of equivalent length should be developed.

The UKCC stipulates that the minimum health visiting training course is 32 weeks. We believe that we should strive for excellence in Wales and immediately extend the length of all courses offered in Wales to 51 weeks

This, we believe, is a matter of public protection, as students and newly qualified Health visitors do not feel adequately prepared for practice following completion of the shortened courses.

Valuable components of the ‘old’ course such as the investigation and compiling of a health needs assessment for an area (neighbourhood study), alternative practice and supervised practice should and could be reintroduced to the longer course. Students felt that these aspects of their preparation for practice needed to be included to enable them to practice public health nursing. We agree with the Review that there needs to be a strong shift in emphasis towards the broader public health role with communities and population as a matter of urgency if health visitors and school nurses are to be adequately prepared to deliver the new policy initiatives.

We recommend that the current curriculum and learning outcomes for health visiting and school nursing should be reviewed by the UUKCC or its successor body as soon as possible.

We strongly agree with the above recommendations and urge the National Assembly for Wales to ensure that this is considered at the UKCC or its successor body as a priority.

We recommend that in order to ensure the quality of professional education in Wales in the short term, the Assembly, in consultation with the professions and the education providers, should use its commissioning power to ensure that appropriate standards for the education of health visitors and school nurses are specified and achieved in Wales.

We believe that the successor body to the WNB in Wales would be ideally placed to provide leadership and a much more coherent, strategic and transparent overview to the commissioning, planning, funding and implementing of health visitor and school nurse education in Wales.

There needs to be a much more integrated approach.

As health visiting is a universal service, it is ideally placed to prevent and detect child abuse. Child protection used to be a key component of the training but has been reduced to a mere 4 hours. This is clearly inadequate.

We believe that the child protection teaching should be increased so that newly qualified practitioners are confident to identify and report child protection issues and fully participate in the preventative or remedial processes.

We are concerned that standards are maintained and that practitioners are fit for purpose.

Because of the reliance on Community Practice Educators to teach 50% of the course curriculum in practice, we believe that CPE’s should be educated themselves to at least first degree level and have adequate trained, rewarded for the extra responsibilities, and have the appropriate reduction in caseload. This is a very important role and because of the perceived devaluing of the role, there is a current shortage in CPTs.

In responding to the document our members expressed concern about continuous professional development. Very few members are fully funded to attend conferences and courses and most are given the time and asked to fund themselves.

Post registration courses in aspects of public health need to be developed and a ‘body’ needs to take a strategic overview of need and commissioning of appropriate courses. Contents of courses should include public health project development: negotiating funding to implement projects, developing evaluation tools and monitoring outcomes.

Our members involved in the Sure Start Projects identified these as essential public health nursing skills of the future.

Opportunities for shared learning with related disciplines other than nursing should be actively sought.

It would be especially opportune to develop multi-professional courses and modules. High quality public health practice opportunities need to be identified urgently, so that the principles of public health can be demonstrated and excellence in practice opportunities identified and shared.

We believe that nursing in Wales must be fully involved in the development of common standards for public health practice, and given the same opportunities to develop as professionals within public health practices as have our medical colleagues.

Close links should be established with the evolving Wales Centre for Health so that the expertise of health visitors and school nurses is fully linked into the whole of the health improvement process throughout Wales.

Priorities for change

We fully agree with the following recommendations and would like the Assembly to note the emphasis on the need for urgency in addressing the information deficit and the system failure.

We recommend that the Assembly should give urgent consideration to the development on an all- Wales basis of appropriate clinical information systems for community health services.

The fact that the finding of the Review demonstrates that the present information systems are so unfit for purpose raises many questions, not only for the health visiting and school health services but also for the future provision of all health services in Wales. The fact that this is a problematic issue at HA and LHG level, and that there is often poor communication between Trusts and LHGs, makes addressing this recommendation an urgent need.

It is impossible to adequately commission health services without information of patient need or of having any understanding of the quality and benefits of what component parts of the health service can offer to patients. Unfortunately the Review also seems to reflect a lack of interest or inability to recognise this as a problem, and the need to be actively exploring constructive ways remedy the situation.

We recommend that a specification for core services to be included in the health visiting service should be developed on an all Wales basis, supplemented by local specifications to be delivered by Local Health Groups on a basis of identified needs of their local population.

Again we agree with this recommendation within the context of a much healthier constituted LHG Board. We would envisage the LHG having an appropriately trained public health nurse at the relevant service levels to oversee this process.

Our members identified time and time again in their comments on the tedious collection of irrelevant statistics only useful during the period of the internal market. This information, as reported in the Review, does not contribute to the process of planning a service based on assessment of client need, and as such is almost worthless.

Very few of our practitioner members throughout Wales had any involvement in formulating local Health Improvement Plans and were not asked for information about the health needs of their clients to inform the process.

Few have any contact with their LHG and are mostly unaware of their plans or influence on local services.

A high percentage of nurse members of LHGs do not feel that the present structure and organisation of LHGs is compatible with leading and developing community nursing services and certainly there is little understanding or sympathy for public health developments within some LHG’s. However, there are exceptions in parts of Wales, and we would recommend that there is a study and sharing of good practice between LHGs, so that there is consistency in development of public health service at community level.

Health Promotion Officers/Advisers to LHGs, although they may be managed within some Public Health Departments and do offer a valuable preventative and health promoting service, do not offer a comprehensive public health service.

There is a side to the public health triangle that is presently missing and will remain missing unless health visitors and school nurses are allowed to practice a community development model to complement family work, public health medicine and health promotion services.

We recommend the retention of health visiting as a universal service for families with children, with intensity of services based on client demand and the health visitor’s assessment of need.

There was universal support for this recommendation from our members. The universality of the service is unique, allows for flexible working according to child and family need and provides health visitors with the insight into communities that is invaluable for public health work.

The health visitor’s role as public health nurse should be integral to the government's attempts to tackle social exclusion. There is no other professional so well placed in communities to identify early when children and families are in need of extra support, to provide that support and to refer onwards to specialist support from other agencies as soon as possible.

Practitioners in some Trusts in Wales find that the shortage of other professionals, such as speech therapists, child psychologists and social workers, leave them as the only professional supporting vulnerable families after they have identified need for support.

The fact that other agencies such as Social Workers are also under pressure makes it even more imperative that the assembly notes this recommendation.

We believe, however, that health visitors should not be used universally by Trusts or GP practices to carry out inappropriate tasks that could and should be delegated to other members of a community nursing team. Our members find that are the giving of routine child immunisations by health visitors often restricts the time they have to carry out other more appropriate work with families.

Wales does not have initiatives such as Health Action Zones and Education Action Zones that have given health visitors and school nurses the opportunity to practice their wider public health skills and their lack of involvement in Healthy Living Centre bid development and Local Health Alliances in some areas is regrettable.

The health visiting services should also be formally extended to include children in other settings away from home, for example in foster or residential care.

We strongly agree with this recommendation as part of a package of greater protection for vulnerable children. In some areas health visitors actively participate in the care plans of children in foster and residential care, but this is on a very ad-hoc basis and needs to be formalised.

Again, we believe that the service needs professional leadership and public health nurses in key positions within Trusts, HA’s and LHG’s to facilitate, plan and implement good quality health protection services for all children. Hhealth visitors and school nurses are ideally placed to support vulnerable children that are looked after and can inform a comprehensive health package for those children. Presently these children have very poor long term health outcomes and often fall through the primary health care net.

We recommend that further work is undertaken by Local Health Groups to identify the need for health visiting services to older people.

We believe that health visitors can offer the elderly a valuable service, a service that was once more or less universally offered, but has again been lost.

The overall benefits working with older people in accident prevention, nutrition, healthy lifestyles can have long term benefits for the health and the social care services.

Again the work to develop an appropriate service by LHGs needs an appropriately trained public health nurse to lead it.

We recommend that new ways of working should be developed and tested in pilot studies within the framework of the developing Local Health Groups in at least three areas covering geographical differences and urban and rural areas.

We feel this is a positive and constructive recommendation.

However, we also feel that the Review demonstrates that presently there is a lack of professional leadership and commitment to the development of public health initiatives in the health service in Wales and to the development of the roles of health visitors and School nurses within the present structures.

Therefore, we believe it would be unwise to proceed with pilots in isolation of other leadership and management mechanisms to support their development and robustly evaluate the outcomes.

We would also like to be reassured that if actioned, this recommendation of ‘pilots’ would not fall into the trap of short term, small gain initiatives that would not benefit all of Wales and the situation in those LHG or Trust areas would revert to the pre-pilot situation.

From our discussions with LHG nurses, the current structure of LHG Boards would not be conducive to the developments of pilots without external support and a facilitated change in Board culture. This may happen simultaneously and as a welcome side effect with the integration of public health into LHG’s.

The Public Health Alliance recommended (1988) a public health model of primary care that could be piloted in Wales to promote the linking of primary care, public health and community services and development.

LHGs will need expert support in planning, implementing and evaluating swift change. We strongly agree and recommend that the Assembly acts with some urgency

Whilst we follow with great interest the current piloting of the Family Health Nurse at Sterling University, we also acknowledge that this is a particular model, developed and piloted in this initial stage for a specific area of Scotland (the Highland and Islands) and would urge the Assembly to await the evaluation of this pilot before embarking on what may or may not be a totally inappropriate model of Community Nursing for us in Wales.

We recommend that Trusts (in conjunction with Health Authorities, and Local Health Groups) should review their public health function and designate a senior manager to take forward the development of the public health agenda.

We fully endorse this recommendation but would like to take the recommendation further in order to ensure that there is long term commitment to improving health by giving this responsibility to professionals that are trained specifically to undertake these roles.

We believe that the way forward is to establish Specialist Public Health Nursing posts both at Trust and at Health Authority/ LHG level for an effective integration of public health activity into Health visiting and School nurses roles.

The Public Health department of Health authorities should have a senior public health nurse that can take a strategic health improvement vision, and promote a public health model of primary care that can develop alongside the populations and community development public health activities.

This post could integrate the public health input of health visitors and school nurses in the Health Service, Health Alliances, Health improvement Programmes, Early Years Partnerships, Sure Start, Healthy Living Centres, and other initiatives.

We recommend that a detailed census of the health visiting workforce, is undertaken as a matter of urgency. In addition to personnel data this should include data about each health visitor’s caseload.

We believe that there is no question that this detailed data collection needs to be done as a matter of urgency.

It is obvious from the Review findings, despite the difficulty obtaining data, and from our responses from members that there are not enough practitioners on the ground at the moment to fulfil the generic role.

Whist the policy and health visitor involvement is welcomed the current workforce is further depleted by the new public health roles in initiatives such as Sure Start.

It was regrettable that the CPHVA and others had to vigorously campaign to reverse the reduction in health visitor student places last year when all the indicators, apart from Trust student requirement figures, pointed to an urgent need to increase student places.

We also believe that the Assembly workforce planning department needs to liase much better with the service and give strategic guidance where putting policy into practice.

School Health Services in Wales

The Review paints an even bleaker picture of the Welsh school nursing services than the health visiting service.

The findings question the present ability of any Trust or Education Authority to provide an adequate School Health Service for children living in their area.

This is regrettable and again directly contradicts policy initiatives and government direction.

There is inconsistency in professional management and leadership, and it seems other than the planning of a basic screening and immunisation programme, there has been virtually no service development for years.

With the present government emphasis on improving teenage pregnancy rates, reducing alcohol and drug abuse in the population, improving nutritional standards and discouraging young people from smoking, to name only a few initiatives that could and should fully involve a school nursing /health service, the present service provision must be unacceptable to the National Assembly for Wales.

It is frightening from a protection of the public perspective that so many senior managers had such a very incomplete picture of what school nurses were doing.

"The Review has revealed a service which is fragmented, grossly under developed, and under resourced ".

We are saddened to confirm this statement and horrified in this post– Waterhouse era to read that the Review considers that some school children in Wales are not receiving services to which they are entitled by law.

We would hope that these are some of the issues that the newly appointed Children's Commissioner for Wales would wish to address in partnership with the Assembly and the service. They are also issues which should be considered by the ‘Carlile Commission’.

We totally agree with all the Review’s recommendation but would go further and seek a Strategic Group to consider the recommendations and take a work programme forward in partnership with relevant stakeholders.

We welcome the Review’s recommendation to explore the CPHVA’s National Framework for School Nursing Practice, but use it as a national model rather than restrict it to a pilot site only.

Some of our members expressed concern that the Review had not considered in more depth the overlap between the school nursing service and the services to schools and school aged children offered by health visitors.

Whilst agreeing with the principle that every school should have a designated school nurse, we believe that the allocation of schools per nurse should be according to the needs of the area health profile.

We strongly agree that service agreements should be negotiated between the NHS, education authorities, school governors and school heads to ensure equity of service provision and also believe that evaluation of the service should be part of the regular school inspection process.

Change in the education and preparation of school nurses as stated in the Review is clearly necessary

We strongly agree that funding arrangements for initial and continuing education for school nursing should be urgently reviewed, and that the whole process should become much more transparent with demonstration of who has responsibility and who is accountable for the process.

The provision of continuing professional development for school nurses must be urgently reviewed and we agree with the Review’s short term solution because the problem needs immediate attention. School nurses should be included in multi disciplinary training.

The examples received from other parts of the UK demonstrating the potential of a comprehensive school nursing service must be allowed to develop in Wales.

We look forward to working with the Assembly to indeed realise the potential of health visiting and school nursing in Wales.

Professional Officer, CPHVA

1st February 2001