Health visitors and social workers to work more closely in early intervention

Health visitors are set for a larger role in early intervention in the lives of vulnerable children. Julie Griffiths reports

Health visitors have often been regarded as the poor relations in the nursing and healthcare world. As a result their numbers have dwindled over the past few years and what was once a universal service to all parents of children under the age of five is now more targeted at vulnerable families.

However, problems in recruiting social workers and the increased numbers of children in care means policy-makers are looking at health visitors to help identify problems in families early on.

The government has pledged to recruit 4,200 health visitors in England by the end of this parliament. Many of them will work in Sure Start children’s centres to support the most vulnerable families.

In addition, the government’s Early Intervention Commission, chaired by Labour MP Graham Allen, is expected to make recommendations about the importance of the role health visitors have to play.

Allen says early intervention is about pre-emptive action that breaks the cycle of dysfunction passing from one generation to the next. But he expects more targeted health visiting services to have an impact on children’s services within the present generation.

“Health visitors are there when a new mum needs a bit of help and she’s open to that support when she may not be at other times in her life,” he says. “It means social workers are freed to deal with harder cases.”

Helen Johnston, programme director for children and young people at the Local Government Association, would welcome widening the health visitor role to achieving more than just clinical targets. She points out that other agencies, including health, have in the past been too quick to pass the buck to social services when it comes to at-risk children.

“Too many referrals make vulnerable children less safe, not more. Other agencies need to use their own professional judgement to assess the risk to a particular child, and provide crucial information in a uniform fashion to reduce the workload on stretched social work teams,” she says.

Rather than health visitors referring problems on to social workers, the model most commonly used at present, there is a growing body of opinion that they should be working together in joint teams.

Nushra Mansuri, professional officer of children’s services at the British Association of Social Workers, is enthusiastic about the idea. She recalls this type of working being commonplace in the 1990s and describes going on joint visits with a health visitor to see a family where there were child protection issues.

“By having different agencies in the same room, singing from the same song sheet, it reinforces to the family that we are really concerned,” says Mansuri. She adds that joint working in this way helps engage families who may be resistant to social worker intervention.

But, although Mansuri cannot see why anyone would resist the idea of joint visits, the union Unite, which represents health visitors, points out some of its members are already buckling under caseloads of more than 600 because their numbers are so few.

Gavin Fergie, professional officer for the trade union, believes an additional 8,000 health visitors are needed to deliver a quality service, so the extra 4,200 promised by the government is insufficient.

Fergie is also critical of the decision to target health visitors at families deemed to be high risk for early intervention work. Such a move undermines the concept of early intervention, he argues.

“If we don’t have a universal service, then those who are teetering on the brink won’t be helped. We’d react to vulnerability only once it had developed into something more,” says Fergie, a former health visitor himself.

He points out that as a universal service, health visiting plays a crucial role in protecting children who are not on social services’ radar. Serious case review statistics lend support to Fergie’s view. According to an analysis of all serious case reviews between 2007 and 2009 by the University of East Anglia, published in September, only 16% of children involved were subject to a child protection plan with another 13% having been the subject of a plan in the past. It also highlights that about half the SCRs were in relation to babies under one year old and nearly half of those were aged under three months – prime health visitor territory.

Health visitors must be given the time to build and sustain meaningful relationships with families and social workers, if any changes to their role is to work, says Dr Cheryll Adams, an independent consultant for health visiting and community health policy. “You’ve got to be in a position where, if there’s a problem, you pick up on it and ask the right questions,” she says.

Adams says current high caseloads mean that most health visitors are fire-fighting and the danger of doing this over many years is that professionals become deskilled.

The answer, she says, is a bigger workforce and more joint training with social workers and other stakeholders.

“I know we’re in a time of financial constraint but joint training is invaluable. You can’t beat face-to-face contact and suddenly you’re seeing things from another professionals’ perspective as well as your own. That can only be a good thing.”

High quality joint working

There are many ways social workers can maximise joint working with health visitors.

● Mutual respect: Nushra Mansuri, professional officer in children’s services at BASW, says mutual respect is an important factor in any close working relationship. Social workers and health visitors should learn about each others’ roles, what pressures they are under, and what targets they have to meet.

● Get to know the health visitors in your patch: Mansuri points out that each health visitor works in a slightly different way. Gavin Fergie, professional officer at Unite agrees. “Even a gesture as small as introducing oneself at a case conference can be a step in the right direction. It’s making the effort to engage.”

● Joint visits: Mansuri believes joint visits streamline services, ensuring a different perspective on tackling problems. They also help both professionals to work towards the same goals. However, before a joint visit Mansuri recommends discussing it in detail before stepping over the threshold. That way, each professional can make it clear to the other what is the most important issue for them and decide on a strategy for handling the visit.

● Informal lunchtime meetings: Dr Cheryll Adams, an independent consultant for health visiting and community health policy, says organising regular, informal lunchtime gatherings for all stakeholders involved with at-risk children in the area means they can network and sustain close relationships. “The important thing is that all those working with children – school nurses, health visitors, social workers, police – could drop-in to catch up with people,” she says. Fergie agrees face-to-face contact is vital for building relationship and sharing information. “It’s not ideal if you’re only in touch via email or when things go wrong. If you sit in the same room, you share and learn and you see each other as different strands in the same rope,” he says.

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