Susan Hill recalls how much she relied on her health visitor and bemoans the decline of this once-universal service: the victim of bureaucratic ‘targeting’ and government ignorance
You can be sure of one thing about government. If it ain’t broke, they will fix it and don’t worry about the breaking bit, they will do that for themselves. Rewind 15 years to the health visitor system which was so ‘not broke’ it was a model for best practice throughout the world. HVs originally looked after patients ‘from cradle to grave’, advising and supporting anyone who needed them, including the elderly, the chronically or terminally ill and the disabled, but gradually their remit narrowed to new mothers and babies and the under-fives.
They were qualified nurses who trained on the job before being attached to GP practices, as part of a mixed-skills team with their own caseload, visiting pregnant and new mothers. They did routine checks and advised on maternity and neonatal problems while learning about family and home circumstances. Even mothers in prosperous circumstances have troubles over their post-natal health, breast-feeding, crying or non-sleeping babies, but everyone had a health visitor and with no stigma attached to her visits. If the HV was worried about a mother or baby’s health and welfare, she was perfectly placed to alert her surgery team. She was on the lookout for postnatal depression, developmental problems and tuned to possible domestic violence, child neglect or abuse. She had access to patient notes and could add her own for the surgery team. Many a crisis has been nipped in the bud by an HV having a quiet word with the GP as they passed in the surgery corridor. Meanwhile, trust was built. Mothers could talk to their HV about things they found it difficult to express to family or even doctors.
Health visitors ran regular clinics, weighed and immunised babies, did hearing and vision checks and oversaw general development. Not much got past them.
Naturally there were problems. A system is only as good as its operators; personality clashes are inevitable. As a first-time mother 30 years ago I had as my HV a judgmental near-retirement spinster more interested in where I bought the curtains than my disappearing breast-milk. Health visitors must be tactful, good listeners, and able to guide, not order about. Most were good at it. When I later miscarried repeatedly, had a premature baby who died and an anxious but successful next pregnancy I had a health visitor who was a marvellous support — relaxed, sympathetic but occasionally bracing, informative and reassuring (though she was in her fifties and unmarried). She was always available in person or by phone. I would not find her so easy to access, so often, now.
High success rates of the immunisation programme are largely due to health visitors’ arts of persuasion. Many cases of postnatal depression were detected early, which led to proper care of the mother and prevention of a whole raft of serious consequences for her family. The balance seemed just right. The HV could reassure, sort out a minor problem, save the GP’s time, alert the team to an at-risk child and prevent a catastrophe. All of this also saved money as well as sanity and possibly lives, and that was important — even in an ideal NHS, resources were never there to be wasted.
I keep using the past tense. So where is the health visitor service now? In a parlous state, that is where. Why? Money, why else? That is not what you will be told of course. The spin is that the system is being improved, brought up to date and into the 21st century — lean, keen and fit for the purpose.
When those who are responsible for managing the NHS budgets, the Primary Care Trusts, could not balance their books they had to make cuts and those are most easily done at the ‘soft end’, such as health visiting. So they picked up their scalpels to perform radical surgery. When this is done on a perfectly healthy patient the result may be, as with any unnecessary operation, that the patient dies or is left severely maimed. When they took a knife to the HV service they maimed it horribly and death may yet result.
First, health visitors were taken away from GP surgeries, without so much as a by-your-leave to the doctors who relied on them, and placed in teams in separate offices, under managers. They were unable to share their case information and could no longer access patient records. Whole building-blocks of experience, knowledge and painstakingly acquired professional skills were demolished at a stroke.
Developmental checks were scrapped and new mothers sent a returnable leaflet on which boxes were to be ticked about their child’s progress. Baby clinics have been cut so that maybe 60 mothers have to wait in a queue to have babies hastily weighed. ‘Any problems?’ They must shout replies over a roomful of screaming infants, with no chance of privacy to ask a delicate question, let alone of the HV picking up on domestic tension or maternal depression.
Oh, but there is always an office number to ring. ‘I called my health visitor 15 times,’ one mother wrote to an internet forum, ‘but she was never there or didn’t reply to my messages. I had so many problems and I felt abandoned.’
The focus now is not on universal care but on the dreaded ‘targeting’ of those deemed to be at risk or socially excluded, and the system is moving under the wing of Social Services with help given only to the most vulnerable — single mothers, low-income families, the unemployed or those with drug or alcohol problems, in the criminal justice system, with a history of mental illness or living in sub-standard accommodation. Of course mothers and children in all these categories may need and should have a good health visitor, but does this mean others are not vulnerable? Postnatal depression is no respecter of persons and even rich babies scream non-stop. I fell into none of the risk categories but my health visitor came to see me when I needed her. My distress and anxiety, physical and mental, after the death of our baby and through the next worrying pregnancy, bore no relation to our income, marriage, professional status or postcode. They never do.
There was no more stigma associated with seeing your health visitor then than your GP. Are new mothers going to ask for informal advice about their child when it is a request that will have to go through Social Services? The visit from the HV is going to be reserved for families known to be in crisis and the arrival of her car will be as noted as that of the police, truant officer or child cruelty inspector.
Just at a time when GP surgery hours have shrunk and there is no reliable out-of-hours cover, young parents will go to see the doctor if their child has a minor problem that would have been sorted out by the HV. And when the surgery is closed? They’ll go to hospital and fill up A&E, of course, and how much more does that cost?
As a result of the wholesale demolition of a fine service, 85 per cent of HVs in a recent survey reported a doubling of their caseload and 60 per cent have over 500 children to look after. Over 70 per cent report that they do not have time to care for even the most vulnerable mothers and children. No wonder they are leaving the service in droves, retiring early or moving over to a management position which has no caseload at all. Those who leave are not being replaced and it is no good for the Tories to promise 12,000 new ones, because this is now a job nobody wants. Those who have left won’t return and even if they were willing, all health professionals will tell you how quickly their skills rust once they are not used regularly. Any HVs who did return would have to retrain, at huge cost. Meanwhile, the latest government plan to make up staff numbers is to give many of the jobs they once did to people trained only to the (very low) Nurser y Nurse Level (NVQ3).
The official argument for insisting on giving older people like me a winter fuel payment, which fortunately I do not need, runs ‘universal provision... not based on want... means-testing-carries-stigma’. The health visitor service was a universal provision. Whatever happened to joined-up government?