Health visitors call for limits on 'impossible' 1,000-family caseloads

Limits should be introduced on the "unmanageable" caseloads of health visitors in England, with some now responsible for more than 1,000 families each, the Institute of Health Visiting (iHV) has said.

The number of health visitors - qualified nurses or midwives who support families with very young children - has almost halved in the last decade.

In January, the Health and Social Care Committee said the government would fail in its ambition to give every child the best start in life, unless it took urgent action to rebuild the workforce.

The Department of Health and Social Care (DHSC) says the government is "committed to strengthening health visiting services".

Emma Dolan, a health visitor with Humber Teaching NHS Foundation Trust in Hull, says her "top priorities" are to spot potential issues early, and offer advice to parents on things like their baby's wellbeing and sleep to prevent problems arising later.

"We want our babies to live long and happy lives [by] giving that support nice and early and making sure that families know what services are out there."

However, BBC analysis has shown the number of health visitors in England has fallen from 10,200 a decade ago, to 5,575 in January - a drop of 45%.

During the pandemic, health visitors in almost two-thirds of hospital trusts were redeployed by the NHS, a decision that was deemed "fundamentally flawed" during the Covid inquiry last year.

Although health visitor reviews with families have broadly returned to pre-pandemic levels, the reduction of staff means health visitors are taking on an increasing number of families.

In other UK nations, there are safe staffing limits - of about 250 caseloads per health visitor - but that has not been applied in England.

iHV chief Alison Morton says families are paying the price for the decline in the workforce.

"We need to set a benchmark, otherwise we're just going to continue to see this decline with hugely unmanageable, unsafe caseloads which are impossible for health visitors to work within," she says.

"Health visitors are having to prioritise, and actually prioritisation has a human cost.

"They're having to tell families: 'I'm sorry, I can't do that extra follow-up visit', when you know it would have made a massive difference to that family."

Even if England did bring in safe staffing limits, according to Morton, there aren't enough health visitors currently employed to provide that level of coverage.

"We need more health visitors so that we can have manageable caseloads," she says.

From late pregnancy until a child is two years old, families in England should receive five health visitor appointments, with the first three visits taking place in the home, according to NHS and government advice.

But that's not currently happening consistently across the country.

As part of the BBC Radio 4 project Today's Babies, the Today programme is following three families over the first five years of their children's lives.

One of those families is Staffordshire-based Elita and Adam, parents to 11-week-old twins Ruby and Ezra.

Their six-week check was carried out in a clinic, rather than in the family home, and the process of getting two newborn babies to the appointment made the experience "a little bit more stressful" than Elita would have preferred.

"I know NHS services are stretched, and it's probably easier just to put somebody in one place, but I think you're missing out on so much and understanding families better [by not] going into a house," Elita says.

Elita hasn't seen the same health visitor each time, despite new guidelines this year for the Healthy Child Programme (HCP) saying families should have consistency with who they see.

"Continuity of care is massive," says Elita, "I don't want to have to spend 10 or 15 minutes of an appointment explaining everything that's gone on."

In Scotland, Anna and Dan - another of the Today's Babies families - will receive 11 mandatory visits from health visitors, more than double the five those in England get.

In Northern Ireland, families get nine visits.

Elita says health visitors could "pick up on so much more" if families in England had the same number of visits as those in Scotland.

But she and Adam say the availability of drop-in clinics, run by health visitors near to where they live, means they don't feel as though they are missing out on accessing help - although it can feel like a "reactive rather than proactive" option.

Registered health visitor Ruth Watts says the high workload is leading to "missed opportunities" to help families.

"Mums may have plucked up the courage to come in that day to talk about their mental health, but then they can't come if there's no slots available," she says.

Watts says this can mean problems aren't being spotted, or families aren't being given the support they should be when they need it.

"We're seeing a massive rise in vulnerable families and families that are requiring more from a health visitor," she says.

Watts began posting advice for families on social media after "seeing so much misinformation online".

She shares content on topics families would usually turn to their health visitor for support with, such as weaning, developmental milestones and potty training.

"With the decline in health visitors, people and parents are reaching more and more for social media," she says, but adds that it should never be seen as a replacement for speaking with a health visitor face-to-face.

"Health visitors in the community are vital in supporting families with health needs, identifying abuse and neglect, supporting with maternal mental health," she says.

"All of these things can be missed if not in the home or face-to-face."

Watts believes the impact of the falling number of health visitors can be seen in the decline in children who are school ready by reception age.

The Health Foundation, a leading health think tank, says the system is struggling, and that we need to think radically about the most effective support for families.

"This means thinking about how to maximise the contribution of the many different professionals working with families, for example through Best Start Family Hubs," Jason Strelitz told the BBC.

A spokesperson for the DHSC told the BBC that they would be setting out plans for health visitors later this year.

"Following a decade of underinvestment, this government is committed to strengthening health visiting services so that every family has access to the support they need," a spokesperson said.

"As we shift care from hospital to community, health visitors will play an important role, including by building on their trusted relationships to help protect more children through vaccinations.

"We will set out plans for the profession in the coming months as we strive to raise the healthiest generation of children ever."

Data analysis by Amy Whittlestone & Amy Jackson