Understanding the threats to Child Public Health Nursing in England –a complex commissioning framework.
Written by Mary Kiddy
The changes to the public health commissioning landscape in England that were instigated in 2012 under the Health & Social Care Act are now coming to fruition, with the transfer of commissioning responsibility for Health Visiting and Family Nurse Partnership services to Local Authority Public Health departments.
In preparation for the changes, the Health Visiting Implementation Plan ran in England from 2011 and finished on 31st March 2015. The aim of this was to significantly increase the numbers of health visitors across England in order to improve maternal and infant mental health, increase awareness of the importance of early attachment and bonding and to provide a platform for improving the health of under 5s through the implementation of the Healthy Child Programme1 [HCP 0-5].
Local Authorities in England will be mandated to ensure that the core elements of the HCP 0-5 are provided locally incorporating the four levels of intervention: Community, Universal, Universal Plus and Universal Partnership Plus. Five core health reviews are included in the mandate: Antenatal health promoting review, new baby review; 6-8 week review; 12 month review and 2-2.5 year review. These reviews cover six high impact areas: transition to parenthood, maternal mental health, breastfeeding, healthy weight, managing minor illness & accident prevention, healthy 2 year olds & school readiness. This is all included in a national specification for the provision of public health nursing of children from 0-5 published by Public Health England2. All this is very positive for the health of children and families, however there are some threats to the continuation of these programmes that need to be more widely understood and challenged if universal access to services led by experienced public health practitioners is to be maintained.
The Family Nurse Partnership3 programme works intensively with selected first time teenage mothers and their infants, up to their second birthday. This is an evidence based programme adapted from an American model, which has strict fidelity principles and requirements; these may be difficult to maintain if contracts are competitively awarded, thus jeopardising the proven benefits of the programme for selected vulnerable families.
2. Time-limited mandates and tendering of services: threats from the commissioning process
Local Authorities will only be legally obliged to provide these services in their current form until April 2017. After this time, they will be able to determine locally the way in which they wish the Healthy Child Programme to be specified and delivered. They are obliged to put all their commissioned services out to tender to ensure best value for money in awarding contracts, therefore these might not necessarily be awarded in future to NHS providers, nor to local providers with good infrastructure and knowledge for successful delivery. School Nursing services have been commissioned in England by Local Authority Public Health departments since 2013 and many have already gone out to tender. Indeed many school nurses and health visitors in England are already employed by non- NHS employers where local authority and health service contracts have been awarded to organisations and companies outside the NHS. Local Authorities have been hit hard by the austerity programme in England and are having to find massive annual savings on already pared down budgets. In many areas the funding for school nursing services has not increased for a number of years, while expectations of providers by local authority public health commissioners grows [service specifications are locally derived from guidance produced by the DH, LGA, ADPH and Solace4] . These are potential threats to the continuation of universal child public health nursing expertise in England, as the costs of registered nurses who have valuable experience, knowledge and skills in working with children and families may come at too high a price.
3. Workforce and investment threats:
Despite the success of the four year Health Visiting Implementation Plan which ran from 2011-2015 and increased overall health visitor numbers by around 40%, the targets set were not met in many areas and caseload sizes have not reduced to expected levels5 [250 families is the recommended level per health visitor]. This compromises the ability of provider organisations to ensure that they are meeting the requirements of the National Heath Visiting Core Service Specification 2015-162 [NHS England, 2014]. In addition, there is now a high proportion of newly qualified health visitors in all areas [up to 50% in some Trusts], who will take several years of practice to develop expertise and confidence in managing child and family public health issues, leaving a weakened support system while the gap is closed. A further difficulty is recruitment of qualified health visitors in many rural and isolated areas, and providers cannot all maintain equity of provision across their services. Increasing demands on staff time for record keeping and data entry combined with lack of fit for purpose electronic systems is also impacting on time as is the increase in safeguarding activity as a result of cuts to Social Service budgets.
4. Fragmentation of school health service provision and threats to child and adolescent public health
School nurse numbers in England have been diminishing over many years and lack of investment in the service has resulted in a loss of service to schools and families. In 2008 there were 2,415 registered school nurses in England. This number dropped to 1,138 in 2010 and 1,216 in 2012 according to the NMC6. This is set against a figure of around 8 million 5-19 year olds in schools in England. Providing a universal service with this meagre resource requires enormous creativity and flexibility on the part of providers and school nursing teams, and is a cause of huge workplace stress. Further investment in virtual school nursing services utilising electronic social media is urgently required to ensure that all young people [including those in rural areas] have access to health advice and support from trusted and experienced professionals. The value of the service was clearly demonstrated by young people in the British Youth Council in the development of ‘Getting it Right for Children, Young People and Families’, DH 20127.
The service to school age children is further compromised by the fact that school vaccination programmes will continue to be commissioned by NHS England, not Local Authority Public Health Teams. This means that where the school nursing service continues to be the local provider of school vaccination sessions, the commissioning and funding streams are split and there is the complexity of managing one small workforce against two separate and demanding contracts both with performance targets built in. All organisations wishing to provide vaccination providers have to be registered as preferred providers with NHS England and many areas have developed separate immunisation teams to manage the demands of the Immunisation contract. It is entirely possible that in some areas of England, school vaccination services will be provided by different employing organisations to the school nursing service, as contracts may well be awarded to different providers. In areas with low investment in school nursing, this is a serious drain on resources. Whilst this may increase flexibility of delivery against tight contractual obligations, it does not promote or support continuity of service provision, or familiarity of a familiar face at a school vaccination session for children young people if they have never met any of the nurses before.
In some parts of England, the commissioning streams for enuresis/continence services and special school nursing services are also split, and this is already leaving gaps in service for children with more complex needs, as well as very limited service provision.
In addition, in some areas, the National Child Measurement Programme is also contracted separately and is not necessarily provided by the school nursing team. Provision of services to school age children in England have the potential to become increasingly fragmented and complicated for schools to manage. Dovetailing the requirements of 3-4 providers rather than just one in a busy school will give rise to dissatisfaction with the service overall and may result in children’s access to the Healthy Child Programme8 [5-19] being compromised.
The issues outlined above are serious and present threats to continued delivery of universal public health to every child under 19 in England. The fragmentation of the commissioning process means that much flexibility in service provision is lost, as monitoring against performance for each contract is tight and therefore, flexibility [all the little extra tasks managed by the school nurse or health visitor that made life easier for a child and family] are disappearing. Staff can only deliver against the programmes they are commissioned and funded to provide, mainly due to relatively low staff numbers and high caseloads. Other teams may provide other parts of the service to the child and family, and gaps will appear between the contractual obligations of each provider. Should the numbers of Specialist Community Public Health Nurses diminish further [as is likely, due to budget restrictions] then these effects will impact on children and families as professional flexibility and attitudes are eroded by a less expert and differently skilled workforce.
6. What can BACAPH do to raise awareness of the threats to child and family public health?
These are issues that require a higher profile, national debate and assurances of maintaining an expertly skilled workforce.
- Working together with the other public health nursing organisations and maximising opportunities to raise awareness with politicians, local government organisations and bodies about the contractual issues is vital.
- Ensuring that all community practitioners understand the implications of the commissioning framework will help to raise the profile.
- Asking members to find out what is happening in their local authority area and to ask their Director of Public Health for assurances that NHS providers will be preferred and that maintaining an expert public health nursing workforce is written into their tender specifications.
Mary Kiddy RGN; RSCN; SCPHN [School Nursing]; MSC [Applied Public Health]; FFPH[formerly Associate Director of Nursing for Children & Families, Cumbria Partnership NHS Foundation Trust]
1 The Healthy Child Programme: Pregnancy & the First Five Years of Life; DH 2009
2 2015-16 National Health Visiting Core Service Specification; NHS England, 2014
3 The Family Nurse Partnership Information Leaflet; DH, 2012
4 Maximising the school nursing team contribution to the public health of school aged children: Guidance to support the commissioning of public health provision for school aged children 5-19; DH 2014
5 Special Report: Caseloads Community Practitioner, May 2015, Vol: 88 No. 5; pp18-20
6 bbc.co.uk 13th April 2013 Link.
7 Getting it Right for Children, Young People and Families: maximising the school nursing contribution of the school nursing team: Vision and Call to Action; DH 2012
8 The Healthy Child Programme 5-19; DH 2009