King (2015) examined health visitors’ accounts of the impacts of ‘Hall 4’ on their practice and profession.  The trigger for the study was health visitors’ strong reaction to the major change in service delivery.  This was a qualitative study which used interviews to collect data. Sixteen health visitors with between 8 and 30 years’ experience took part in the study. The findings of the study were that the implementation of ‘Hall 4’ had impacted negatively on health visiting practice and morale. The researcher concluded that health visitors play a crucial role in policy implementation and their feelings can shape how families experience the service.  Recommendations were made to engage health visitors in consultations about changes to policy.

• What do you think may be the consequences of targeted rather than universalistic health visiting practice?

Answer:

1. Increased demand on GP and other clinical services due to decreased support from the health visitor for routine queries.
2. Decrease in levels of school readiness resulting in increased levels of late referrals to services such as Speech and Language.
3. Escalation of long term behavioural problems resulting from a lack of small scale early interventions

Eating difficulties resulting in over or underweight children due to an absence of advice in the early stages, i.e. when progressing/changing from breast to bottle feeding, weaning, fussy eaters.

Access the ‘Foundation Years: Great early years and childcare’ website: www.foundationyears.org.uk/health-integration-in-practice-2/early-intervention/

Click on the link to the Marmot Review, Fair Society, Healthy Lives (2010) and write a brief summary of the report and how it will impact on your practice.

Answer: A summary of the report and main findings can be found at:

www.local.gov.uk/health/-/journal_content/56/10180/3510094/ARTICLE

Teenage parents Jade and John are invited to an appointment for Beau’s 12-month review at the local Children’s Centre. The appointment is sent well in advance. The health visitor, Sally, sent a reminder text to Jade’s mobile phone the day before. There was no response. On the morning of the appointment neither Jade nor John attend with their daughter Beau.

Sally decided to complete an opportunistic home visit rather than invite them to another appointment because the parents have not brought Beau to the clinic or been seen for some time.  When Sally visited, Jade was found to be at home with Beau. Jade let Sally in and disclosed that her relationship with John had broken down.  She was in debt and felt very low. Sally was able to actively listen to Jade, complete a mood assessment and signpost her to the local Depression and Anxiety service. Sally was able to offer weekly listening visits whilst Jade awaited the appointment. Jade was encouraged to access the Children's Centre to support her in managing debt and to socialise with other mums. Beau was assessed as meeting her developmental milestones and her growth was satisfactory.  Sally offered visits by the Community Nursery Nurse to support the relationship between Jade and Beau. Sally decided to defer some of the Health Promotion activities usually carried out during the 12-month review until future visits because she wanted to prioritise Jade’s mental health and her relationship with Beau.

• How is health promotion defined by the World Health Organisation?

Answer: ‘Health promotion is the process of enabling people to increase control over, and to improve, their health. It moves beyond a focus on individual behaviour towards a wide range of social and environmental interventions.’

• List the health promotional activities usually carried out at the 12-month review?

Answer:

1. Prevent obesity and promote healthy behaviours
2. Review immunisation status
3. Raise awareness of dental health and prevention
4. Advice and information on healthy weaning, portion sizes, types of food and meal time routine, feeding cups, Healthy Start and vitamin supplements, including risk factors for obesity and awareness of iron deficiency
5. Raise awareness of injury and accident prevention including safety in cars
6. Offer advice on smoking cessation and preventing passive smoking
7. Raise awareness of skin cancer prevention

Angharad is 3.  She lives in a deprived area with her mother, Sian, and her sibling Tom, aged 9.    Angharad was last reviewed by the health, Jane, when she was aged 18 months.  At this time her development was satisfactory. At the three-year check Angharad’s development is significantly delayed.  Angharad says very few words.  She grunts and points to make herself understood but she appears to understand what is asked of her. Her fine motor skills development is delayed; she is unable to hold a pen and is still using a ‘palmar grasp’ to pick up small objects, rather than the ‘pincer grasp’ expected at age 3 (Sharma and Cockerill, 2014).  Her gross motor skills are also delayed; she is unable to ride a tricycle or kick a ball. The health visitor discusses her concerns with Sian.  She is mindful of using a non-judgemental and supportive approach. Sian is unconcerned, stating that Angharad is lazy. However, she agrees to Community Paediatrician and the Speech and Language Therapist (SALT) referrals.  Jane discusses ways in which Sian and Tom can encourage Angharad’s speech development in the meantime.

The Community Paediatrician advises Jane that her assessment identified global developmental delay due to insufficient stimulation.

Sian does not take Angharad to the SALT appointment.  The SALT offers another appointment but they do not attend this either.  Sian tells Jane that she doesn’t see the point as she is not worried about Angharad’s speech.

• Explain the value of universalistic services in this scenario.

Answer: The family are living in deprived circumstances.  Those from lower social classes are generally known to access health services less than more affluent sections of society.  This is either because they do not perceive they have a need or there are barriers (real or imagined) to them accessing services.  Clearly Angharad’s mum did not think that her speech or other developmental delay was a cause for concern.  Therefore, if a routine 3-year check had not been scheduled by the health visitor, Angharad’s mum would not have approached the health visitor.  In this instance Angharad was so under stimulated that she had regressed.  The undertaking of the 3-year check provided the opportunity for this to be identified and raised as an issue.  Without this it is likely that Angharad would have started school at a distinct disadvantage in comparison to her peers.  The under stimulation is something which could be attributed to a lack of knowledge or awareness, lack of focus on the child or even convenience as Angharad’s lack of mobility and dexterity would make her easier to look after than a mobile, active child with the fine motors skills to explore her environment. However, non-attendance at two SALT appointments would escalate the health visitor’s concerns and this may become a safeguarding issue as Angharad’s needs are being neglected. Whatever the eventual outcome it is clear that had this assessment not taken place there would have been no opportunity for identification of need, appropriate referral or further monitoring to ensure that Angharad reaches her potential.

• Why is a non-judgmental and supportive approach essential when working with families who have failed to meet their child’s needs?

Answer: Adopting a non-judgemental approach is a fundamental aspect of nursing practice.  This is perhaps of even greater importance when home visiting as you are a guest in the family home and have no right of entry under the law.  This aside, it is imperative to act in the child’s best interest and you can only do this if you form a partnership with parents/carers.  They are very unlikely to respond to your suggestions if they feel you are implying they are a bad or inadequate parent.  Alienating parents is likely to result in refusal to admit you to their home and/or interact with you in the clinic setting.  You are powerless to help if you are unable to interact with them. Nevertheless, the health professional needs to ensure that what needs to be said is clearly stated and not ‘glossed over’ or trivialised.  This requires tact and diplomacy, whilst being clear and assertive. Skilled support from a health professional can empower families to take control over their own lives, making and sustaining changes which improve their health and wellbeing.   This is often a painstaking process whereby small steps forward often alternate with big steps backwards.  Therefore, a sustained supportive relationship is crucial.