My Reflections on Health Visiting over the Last 34 Years

I became a health visitor in 1991 and over the last three and a half decades, I have seen many changes in health visiting. I left the acute setting after 8 years of practice as I wanted to make a difference. I was very disillusioned with seeing sick children being admitted with health issues that were preventable. I wanted to move into health education to help parents keep their children out of hospital and prevent ill health.

The book ‘Health Visiting in Practice’ (Robertson, 1988) was my bible; the four basic principles of practice set back in 1977 by the Council for the Education and Training of Health Visitors are still my mantra today.

1. The search for health needs

2. Stimulation of the awareness of health needs

3. Influence of policies affecting health

4. Facilitation of health-enhancing activities

When I qualified, I entered an extremely rewarding profession in which I knew my families very well. I had my own caseload, and I built up very strong relationships with my families. Health visitors would do their first contact visit in the antenatal period to get to know the parents before the birth of their baby. Families would have the same allocated health visitor who would stay with them until their child reached school age. I went to work every day feeling happy and felt I was making a difference in parents and children’s lives. The service was excellent as I was able to intervene early and identify when things were not right. We delivered antenatal classes jointly with the midwife and followed up with postnatal classes. We also offered weaning groups, helping new parents to make healthy choices in what their babies ate. An important part of the role of the health visitor is to support the mother’s emotional well-being and when they felt low, we would offer listening visits. This worked well as they knew and trusted us as their health visitor.

When I qualified as a health visitor, our training was very robust. I trained under the diploma model, where we received very robust training with many subject matter experts coming in to educate us on various subjects that we needed to equip us for the role, such as dietitians, sleep experts, behaviour experts, and public health experts to guide us on immunisation and, health and safety issues. Sadly, since health visiting has gone to degree level, the focus has shifted more towards academic knowledge rather than the practicalities needed to support health visitors in their everyday job. I consider myself very fortunate to have undergone such robust training to equip me as a health visitor.

Over the years, health visiting has gone through many changes, with the introduction of corporate caseloads and skill mix. This meant that new parents no longer had an allocated health visitor, and the close bonds that formed previously were now disappearing. Corporate caseloads meant that the workload was now allocated among a team of health visitors, leading to the loss of the bonds once had with families. Skill mix meant that health visitors no longer conducted developmental checks for children, further reducing the bond and relationship we had previously formed in our health visiting role. Many of my colleagues were leaving the profession as they no longer had job satisfaction.

In 2000, the training for all nurses, including health visitors, changed to degree level. The focus was on academia and how to write an essay that was correctly referenced and research-based. The practicalities were no longer the focus. Health visitors were now completely reliant on their practice teacher to teach them the practical skills needed to equip them for the job.

The Health Visitor Implementation Plan, introduced between 2011 and 2015, was a plan intended to recruit more health visitors into the profession; unfortunately, this plan had faults. When I applied to be a health visitor all those years ago, you were not considered unless you met the criteria. The applicant had to be dually qualified, meaning two qualifications (I myself am an adult nurse and a children's nurse). You also had to have two years post qualification to ensure that you had embedded your practice before being considered for an interview. The fault with the implementation plan was that newly qualified nurses from any background could be accepted into training as health visitors without having the two year’s post qualification experience. I saw so many of these newly qualified health visitors recruited who were ill-equipped to do the job and unable to cope with the demands, leading to their departure within a year or two. Being a health visitor is a high-pressure job; you are out on your own in the community with no support, and you have to be able to think on your feet. You are alone in making decisions about families and what their needs are, requiring a significant amount of training and experience to get it right. This is one of the reasons I wrote my book in 2014, ‘How to be Your Own Health Visitor’ https://www.amazon.co.uk/How-Your-Own-Health-Visitor-ebook/dp/B00KWLLGQ4 I wanted to share my knowledge, skills, and experience to help parents by providing them with the information from an expert.

In 2015, health visiting commissioning went from NHS England to Local Authority, where now non-clinical staff were making decisions about the future of health visiting. The focus shifted to meeting targets, and the quality of health visiting was affected. Health visitors no longer had control over their diaries or how long they spent with families; administrators were booking visits with a fixed allocation of time to meet these targets.

Health visiting at the current time is primarily based around child protection and safeguarding children from harm. Health visitors will still conduct the new birth visit, but more often than not, the follow-up visits will be carried out by a member of the skill-mixed team.

Health visitors are really struggling in the profession now and that makes me sad as health visiting has always been a very rewarding profession for me. We are in a very privileged position, trusted to go into people's homes, where they welcome and invite us in. I have always loved my role as a health visitor, but I find that I no longer get to do what I came into health visiting to do, which is still Health education and promotion that is still needed for parents.

As an expert witness, I wonder how these changes to practice over the years have contributed to some of the cases that come to me for consultation.

Ann Guindi – RGN, RSCN, RHV, BSc (Hons) Nursing and Psychology, MSc (Therapeutic Counselling), MBA, Post Graduate Certificate in Safeguarding Children. Queen’s Nurse.