Health visiting in the UK in light of the COVID-19 pandemic experience: (RReHOPE) findings from a realist review

Health visiting contacts

The practice of health visiting rests on the conduct of ongoing holistic assessments of family needs, conducted by experienced professionals, so that the families and practitioners can identify any support required for the baby/family to thrive. Our findings highlight the importance of these universal assessment reviews, particularly in terms of ensuring potential needs are not missed, and enabling the team to provide a proactive and personalised response to the changing needs of babies, young children and families. While a proportion of reviews was always missed prior to the pandemic (national data sets on this are poor but all highlight gaps), the COVID-19 pandemic meant many more were either missed or were conducted differently. Across our data, practitioners and families express concerns about potential needs not being identified in good time (CMOC01). An increased number of contacts were made remotely, for example, via telephone or with questionnaires sent by post, and using a wider staff skill mix. Our data suggest that such contacts can sometimes enable useful information to be gathered, and that this information can support an assessment of needs (CMOC02). However, face-to-face contacts play a crucial role since they can gather information through physical observations and interactions which might otherwise be missed (CMOC03). Our data highlighted practitioners’ concerns about not being able to assess a family properly remotely. This was recognised to have an impact on other parts of the healthcare system, for example, when issues were picked up later by other healthcare professionals.

Our findings also illustrate the role face-to-face universal assessment reviews play in building trusting relationships with families (CMOC08). From the health visitor’s perspective, these universal assessment reviews enable them to identify problems which parents might have missed, to intervene early, to tailor advice and support for each family and to have sensitive conversations with families. The need for this appeared to be heightened when more families were under considerable pressure (e.g. caused by the pandemic response and cost of living crisis).

From the parents’/carers’ perspective, our data suggest that families feel more supported when they have an opportunity to build a relationship through face-to-face contacts; such contacts facilitate a better understanding of the family context (CMOC09), and families are more likely to disclose their concerns. However, outside the universal assessment reviews, remote contacts can be useful for certain families at certain times. For example, when health visiting teams use remote contacts to proactively maintain open and responsive channels of communication, parents can feel supported (CMOC12). During the difficult times of the pandemic response, some families found a quick ‘check-in’ (e.g. by phone or video call) by the health visitor made them feel that somebody was interested in them, and had remembered them, even if they didn’t receive a longer face-to-face contact.

From the health visitors’ perspective, practitioners might successfully use remote connections to keep in touch with families on their caseloads, when it is appropriate to do so (CMOC11). With no travel time required, remote connections can allow practitioners to be in more regular contact with multiple families, for example using WhatsApp groups to disseminate information. Some families, however, do not have the resources or desire to engage meaningfully with remote consultations and the substitution of face-to-face contacts accentuates the disparities between individuals who struggle with non-face-to-face interactions, and those who are accustomed to and excel in an online environment. The needs of babies and young children are an important consideration in the choice of method of contact, since they are generally excluded from any remote form of interaction (CMOC10); in face-to-face contact, health visitors can directly observe mother–baby interaction, development, play and feeding.

During the pandemic, urgent and immediate needs took precedence, resulting in less time for providing families with holistic, preventive support. Our data highlight health visitors’ concerns around not being able to fulfil their health promotion and wider support role adequately, given demand and caseloads (CMOC04). The pandemic exacerbated issues already seen with high workloads. From the families’ perspective, regular contacts with the health visiting team enable the building of supportive relationships and increase opportunities to explore aspects of family/infant health and well-being, particularly as families’ needs change over time (CMOC05). With fewer face-to-face contacts, there were missed opportunities to provide tailored support that benefits from physical presence, for example, demonstrating or role-modelling activities. However, the pandemic experience also highlights that some forms of information, guidance and support can be usefully delivered by health visiting teams in a digital format (e.g. apps, videos, links to support groups) (CMOC06). Digital/remote provision is only useful for some support, for some people, some of the time. New digital resources were created during the pandemic, continuing a trend that had begun prior. While this gives health visiting teams useful new ways of delivering information and support, there is little evidence of evaluation of these resources, and there appears to be duplication across different local areas (CMOC07).

Health visiting connections

Health visitors are only able to support families in a holistic way by making connections to other services and to the wider community. This relies on a sound understanding of the communities they work in, an up-to-date knowledge of local services and good relationships with other professionals working in their communities. The COVID-19 pandemic response disrupted the continuity of care, with greater mobility of staff within and between health visiting teams, and redeployment of staff to more acute services. Community contexts were also disrupted, with many services closing, reducing capacity or becoming less accessible, for example by increasing their thresholds for support. Our findings highlight that when other services in the community close, or change their provision, then health visitors cannot perform a vital part of their role, signposting and referring families for additional help (CMOC13). Health visitors may assume additional responsibilities in situations where other forms of support are lacking. This may include managing cases that would previously have been handled by children’s social care, or assisting children who are awaiting a diagnosis for special educational needs or disability support. Furthermore, health visitors may go beyond their usual duties to help families with tasks such as translation, form filling and accessing food banks, which are typically supported by local charities (CMOC14).

Some aspects of the wider community provision could not be easily replaced during the pandemic, such as local peer support and socialising groups for babies. Our findings suggest that children and families missed out on opportunities to socialise and take part in different activities (particularly those that support learning and development), which potentially increased the risk of social isolation and stress on parents (CMOC15). From the families’ perspective, our data highlight the concerns of parents regarding children’s lack of contact with other people outside their close family, and particularly opportunities to socialise with children of their own age. Fun activities/groups also provide a useful structure to parents’ days, enabling them to venture out of the house, connect with other parents and experts and try new ideas for engaging their children.

During the pandemic response, informal contact was generally restricted between members of health visiting teams and others, such as clinicians. Our findings highlight that these connections are important for staff well-being and development. Data point to issues of workforce stress and isolation related to this lack of connection, and fewer opportunities for informal discussion, support and peer review, alongside formal clinical supervision and reflection (CMOC16). There are indications that the increased stress and isolation resulted in mental and physical health impacts for some health visitors, including reduced self-care, burnout and lack of compassion for families on their caseload (compassion fatigue).

Digital and remote technologies were increasingly used as a substitute for face-to-face interaction between staff. Our findings suggest that the use of such technologies can enable peer discussions, team meetings and delivery of some types of education, and can increase access to training and networks that may not be available locally. They can also be an efficient use of time when combined with more traditional communication and education routes (CMOC17).

The health visitor role depends on good interagency working, particularly with regard to safeguarding which relies on the appropriate sharing of information between professionals and agencies. Our data highlight the importance of the health visitor’s role in making connections with other agencies such as social services and general practitioner (GP) surgeries. During the pandemic response, many other agencies, schools and child-care settings were not seeing children face-to-face. Health visitors’ connections to other agencies were disrupted, at a time of increased concerns regarding parental mental health, domestic abuse and issues of child safeguarding. In some areas, due to redeployment and workforce shortages, there were not enough health visitors to meet the scale of need (CMOC18).

Health visiting workforce

Health visiting work relies on skilled practitioners, able to exercise professional judgement to identify and respond to needs in an appropriate and tailored way. Health visitors and other members of health visiting teams had varied experiences during the COVID-19 pandemic in relation to the guidance they were given, the procedures they were asked to follow and the restructuring of provision. There was also considerable variation in the extent to which health visiting team members were redeployed to support other parts of the healthcare system, and the extent to which health visiting teams were protected, or even enhanced, during the height of the pandemic. Across our data, being or feeling valued as a highly trained specialist is an important theme. Findings highlight that top-down guidance, updates and restructures often did not reflect the policy and professional commitments to babies, children, families and health visitors. When health visitors in some areas were seen as dispensable and able to be redeployed, they felt particularly devalued (CMOC19).

A related theme is the extent to which government policy focused on managing acute care during the COVID-19 pandemic, with a focus on babies and young children being largely absent. Much literature reflects that younger children were not considered a priority for policy and decision-makers during the pandemic response. The divergence in policy across the devolved nations, and across local authorities within England, also led to different models of support for parents with babies and young children (CMOC20). This situation exacerbated pre-existing workforce pressures, sometimes pushing health visiting services close to breaking point, with a range of negative consequences being reported within the literature for staff, families and children (CMOC21). Understaffing, redeployments, staff illness and health visitors leaving contributed to increased workload and work-related stress for remaining health visitors.

Holistic assessments for early intervention

Health, developmental and other problems within a family can be identified early and mitigated with the help of skilled practitioners. Our findings show that maintaining this role is a key concern for health visitors. It is important to conduct holistic assessments and identify needs soon after every baby is born. However, family situations and child vulnerability are dynamic. The assessment of needs by health visitors is articulated in other research as an ongoing process, with repeated iterations facilitated by the continuous provision of a comprehensive service that covers the period from pregnancy to starting school. 10 While face-to-face contact is critical for holistic assessments, remote contact can be a useful way of keeping in touch with families and making sure emerging needs are not missed. They can also help families keep in touch with the health visiting service and feel less isolated.

When the need for support is identified, practitioners are then concerned with ensuring that those needs are met. In a context that was rapidly changing, the importance of a health visitor’s role in signposting and making referrals was highlighted. 66,67 Where other services and/or informal support becomes less available or accessible, this presents additional challenges for health visiting teams. 68–70 Health visitors, as skilled public health practitioners and as a key part of a local child/family health and social care system, tailor their advice and support within a particular context. Some forms of support rely on face-to-face contact. However, the pandemic has shown that some support can be provided to some families using remote methods. Digital technologies, if evaluated, can provide a quick and acceptable mechanism for providing information to multiple families at once. Parent–peer support can also sometimes be facilitated in creative ways.

Health visiting contacts

1. Health visiting contacts are vital opportunities to gather information for an assessment of the needs of babies, children and their families. All families should know what to expect and what to receive as part of a prescribed schedule of universal reviews that are sufficient to identify their needs. Since assessment is a continuous process, some light-touch contact/check-ins are important between universal assessment reviews. All relevant forms of contact with families are useful, but the additional benefits of face-to-face contact over remote connections must be recognised.

2. Health visiting contacts provide an opportunity for preventive, holistic support. Health visiting teams must have sufficient capacity to provide this service, beyond responding to immediate needs.

3. Health visiting contacts are an opportunity to build relationships and provide reassurance. Universal assessment reviews should be conducted face-to-face by a qualified health visitor, with whom families can build a relationship over time.

4. Remote contacts can prove beneficial for some families during particular periods and can provide a means of establishing open communication channels and offering assistance or information when needed. However, practitioners must consider inclusivity in relation to remote service delivery, and the potential to disadvantage some families.

5. Digital resources can be a useful way of providing additional support; however, practitioners must be assured that such resources are of high quality. Furthermore, alternatives should be in place to meet the needs of families living with digital poverty, to avoid inadvertently widening inequalities in access and outcomes.

Health visiting connections

1. Connecting families with other services is an important part of the health visitor’s role. Health visitors should be supported to highlight where local service provision is missing and to advocate for additional local investment to strengthen the system of support for families across a range of health, education and social needs.

2. Connecting with other health visitors is important for staff well-being and development. Digital and remote technologies might be considered for certain staff training and team meetings, but these should be combined with more traditional communication and education routes.

3. Interagency work is an important part of the health visitor role. Health visiting and other services/agencies involved in safeguarding children must support each other and co-ordinate service delivery, to maintain the visibility of children during times of crisis.

Health visiting workforce

1. Health visiting should be appropriately valued for its impact on child and family health and for longer-term public health outcomes. Universal home visiting services, dedicated to new parents and children, are ‘vital services’ and should therefore be protected in any future emergency. The long-term repercussions of the pandemic response for certain children and for health visiting teams remain partially understood. Additional organisational support may be required to mitigate its impacts.

Health visiting contacts are an opportunity to gather information for an assessment of need for babies, young children and their families

CMOC01: When health visiting teams are not picking up issues through routine surveillance (C) educators and health professionals might see differences in their cases (O) because issues (e.g. developmental issues) are not recognised in a timely way (M)

Vicky Thomas, consultant paediatrician at Newcastle Hospitals NHS Foundation Trust, says that the lack of health visitors has affected children they have seen, especially in the pandemic.

‘The particularly striking issues we’ve seen have been around developmental issues; several children have presented much later than we would have hoped because the routine surveillance of all aspects of development was one of the major casualties of the pandemic’ (Wilkinson-2022). 186

Routine enquiry is more difficult through virtual or telephone methods. It is recommended that health visitors explore open questions about relationships and support networks if they are unable to see a new mother in person (Boddy-2020a). 100

Thomas’s department has also seen a lot of anxious parents bringing their children to the emergency department with the sort of concerns that would be better dealt with in primary care or that maybe don’t even need any medical attention.

‘Health visitors have a vital role in supporting families with these sorts of anxieties and signposting them to appropriate resources’, she says. […] Thomas is most concerned about vulnerable people who have lost an important line of protection or support, including those with complex medical needs or living in poverty, or whose parents aren’t fluent English speakers, or are suffering from mental health problems or addiction. ‘At worst I think there has been a significant risk that children across the country who were vulnerable to neglect or abuse by their parents have been invisible to professionals’ (Wilkinson-2022). 186

Service providers also highlighted this issue, noting that the lack of physical proximity to mother and baby had hampered their ability to identify potential tongue ties and that, during the pandemic, often they only diagnosed this because of how badly damaged the mothers’ nipples had become and how it impacted the emotional well-being of breastfeeding mothers (Public Health Agency-2021). 67

CMOC02: When a family is contacted by phone/video soon after the birth (C) health visiting staff might be able to detect concerns that they can raise with the health visitor (O) because some forms of assessment are relatively easy to do remotely (M)

We are only doing home visits if absolutely required. All contacts are by phone, for NBV calls are made day 4–7, 7–10, and day 10–14. We rotate into hubs to provide HV telephone support daily and offer one clinic a week which is risk assessed by HV and they have to have an appointment. We are being very well protected and the feedback from clients is very positive too (iHV-2020). 132

And, after months of online delivery, there is a good deal of clear thinking on the ground about what a successful hybrid model of online and in-person family support might look like, and the circumstances in which to most effectively deploy different online tools. Most professionals and service leaders foresee an expanded role for virtual family support, but also acknowledge that a blanket approach risks excluding some families, or failing to fully identify and respond to their needs (1001Days-2021). 80

CMOC03: When there are fewer face-to-face contacts between a health visitor and the family (C) health visitors might miss important information or cues related to needs (O) because physical observations are an important part of assessing needs (M)

I was recently talking to a student health visitor who told me about new ways of working remotely where she is placed. The part of the job that she found most difficult was not being able to see the home setting and make a comprehensive assessment of the environment. She worried that she was not going to be able to detect issues around safety or safeguarding as easily (Brook-2020). 101

Ensuring the privacy and safety of service users; assessing children’s development; identifying safeguarding concerns; identifying parental mental health concerns; and building trusting relationships and rapport with parents. Whilst these issues are a concern for many service users, they are particularly concerning for babies, who are especially vulnerable and can be invisible in online contacts. Digital and telephone contact is also challenging for assessing early childhood development, as a report by Action for Children observed, ‘It can be more difficult to engage younger children through digital methods. Activities focused on development for young children are often reliant on things like eye contact, direct speech and the manipulation of objects, which are harder to implement in digital delivery’. When working with a baby, professionals must also engage with the parents and with the relationships between the parents and the baby. Observing the different individuals and their interactions is an incredibly important part of work with the family and is difficult in the absence of face-to-face contact (Best Beginnings-2021). 94

There has been an increase in home working [by health visitors] since the pandemic which may have added to this reduced visibility. At the same time, ‘the retraction of universal services’ and reduced face-to-face contacts have affected the ability of professionals to identify ‘ “new” or increased need, and safeguarding issues’, despite health visitors working very hard to adopt some new and innovative ways of working during the pandemic (Appleton-2021). 79

Between March and early June, NHS England advised providers of community services to release capacity to support the COVID-19 by reducing health visitor contacts from 5 mandated contacts to 2 virtual contacts, with additional contacts available for those previously identified as vulnerable. In this period, there is an increased possibility that perinatal mental health issues may not have been identified, and this is particularly concerning for assessing infant mental health and safeguarding concerns, given that cues will likely be non-verbal and dependant [SIC] on professional skill and knowledge (Action for Children-2020a). 78

Face-to-face contacts should be prioritised for families who are not known to services to mitigate known limitations of virtual contacts and support effective assessment of needs/risks (NHS England-2020). 159

Health visiting contacts are an opportunity to provide information and support

CMOC04: When Health Visitors have a manageable workload (C) they are more able to provide holistic support to the family (O) because they are not just in ‘fire-fighting’ mode (responding to most immediate/high priority needs amongst prioritised families) (M)

Joanne Gill, an experienced health visitor in Somerset, says that they are really just firefighting. ‘We used to be able to do much more one-to-one work; there’s not enough staff for what we really want to do’. She has seen the effect of the pandemic first hand on the mental health of families and children’s development, and the thought that children might be falling through the net ‘is a constant fear’ (Wilkinson-2022). 186

When Phillippa Guillou had her daughter in 2020, she was determined to breastfeed, but it was painful and there were problems with latching. She tried calling and texting her health visitor for help but got nowhere. Two months later she received a response and a referral for tongue tie, but by then she’d had to start using formula milk. ‘I was really upset about breastfeeding. I didn’t have any friends or a network that could help me – and when I called a charity, they said there aren’t any services locally, can you pay for a private consultation? But it was £200, and I didn’t have the money. I’m still sad about it’ (Wilkinson-2022). 186

The health visiting staff provided us with many sad and worrying accounts. Respondents expressed feelings of panic and anxiety, of feeling overwhelmed and being exhausted. We received reports of extremely low morale and finding the job demoralising. Feeling undervalued by managers and their employer was cited by a number of respondents – one individual told us that ‘the job is now, more than ever, about ticking boxes and not assessing and determining health needs’ (Conti-2020a). 31

CMOC05: When there are very few or no contacts between health visiting teams and families (C) some families will feel less supported (O) because they feel they have been ‘abandoned’ by the health visiting service (M)

I had my twins 6 weeks ago, 2 weeks into lockdown they was in NICU for 10 day as I was 34 weeks and 5 days when they born. Just under 4 lbs for both …. Since having the care from NICU I had seen one midwife and one health visitor, I feel like we was just given the babies and basically keep them alive … (Best Beginnings-2020). 93

Many families felt their health visitor was less accessible at this time, while children under two experienced disproportionately high levels of harm due to pandemic measures that were designed to protect the nation, research found (Cole-2022). 104

In particular, the value of an effective health visiting service is being recognised, with families speaking out on social media about the effects on them and their children when they miss out on this vital support. …Frustrated parents have criticised health visitors for a lack of face-to-face contact, with suggestions that they have been ‘allowed to bow out’ during the pandemic. Some stories on social media are heartbreaking. …To be clear: health visitors have not bowed out. They should feel proud of all they have achieved against the odds. The Institute of Health Visiting (iHV) has been overwhelmed by how services have adapted to support as many families as possible (Morton-2021). 158

CMOC06: When a family is contacted by phone/video (C) staff might be able to direct families to digital interventions or other support (O) because some forms of information and guidance are easy to give this way (M)

The guidance supports blended models, stating that ‘health visitors should use their clinical judgement to identify whether virtual, other digital or blended approaches can be used to support the needs of a child or family’ (Best Beginnings-2021). 94

Possible solutions showing utility are digital interventions. Digital interventions have been effective in reducing postnatal anxiety around parenting practices and improving infant health outcomes pre-pandemic. Future research should aim to examine the feasibility and acceptability of psycho-educational interventions to help reduce maternal anxiety, to dissipate misconceptions about attending essential hospital appointments through the remainder of the global COVID-19 pandemic (Jackson-2022). 151

Quality-assured digital interventions such as the NHS-approved Baby Buddy app provide a vital source of 24/7 support for parents and caregivers of all backgrounds, encouraging them to access frontline services. Digital and online services can benefit families in many ways, and, in some cases, the ‘digital pivot’ of services that would usually be face-to-face has led to innovation and the development of new delivery models which bring clear benefits for service-users and organisations. There clearly are benefits of online and hybrid models of service delivery (which use a mix of digital and face-to-face models) in some contexts. Research during the pandemic has shown how digital services, when delivered alongside face-to-face public services, can improve outcomes for babies and their parents (Best Beginnings-2021). 94

As well as the switch to phone and video therapeutic work, The Little Minds Matter: Bradford Infant Mental Health Service have recognised the stress facing families, and have worked at pace with local partners, like Public Health, to create a video to help parents who were struggling to care for a crying baby which has been widely accessed via social media (Best Beginnings-2020). 93

CMOC07: When Covid-19 prompted the creation of new digital resources (C) health visitors had different opportunities to provide information and support to families (O) because such resources are easily shared via remote contacts (M)

Mothers considered WhatsApp an excellent tool in providing an instant source of breastfeeding support, vital when they could not wait for the next scheduled online support group or one-to-one video call. […] ‘WhatsApp group is fantastic. You don’t need to wait for the call, but someone will come back to you. Some things you don’t want to wait for an answer on and mums always have the answers’. […] The platform itself was considered very convenient, in that, mothers did not need to seek or research the information, or the support they needed, as they knew they could get this quickly and via their phone. It was also helpful that mothers could use WhatsApp to call service providers, could send texts, as well as share photos, videos and voice notes. This flexibility meant that mothers felt they received well-rounded support on this platform. […] Mothers enjoyed the mix of professional and peer facilitation (Public Health Agency-2021). 67

As COVID-19 struck and lockdown meant that expectant and new parents were cut-off from their family and support networks, Baby Buddy stepped up as a ‘digital best friend’, with personalised daily information, 300 + films and 24/7 access to the Baby Buddy Crisis Messenger. Pre-pandemic, most parents were recommended to use Baby Buddy by their midwife, health visitor or GP. So, with lockdown and the resulting reduction in face-to-face appointments, we were expecting fewer new registrations. Instead, we have seen 16.7k new registered users during the ‘core’ lockdown period (23 March–4 July 2020). This is a 9.3% uplift on the same period in 2019 (Best Beginnings-2020). 93

She (CNN) first phoned me a couple weeks ago to check in on how I was doing with feeding my baby. It was so nice to hear from someone with useful tips and support & even though I couldn’t have anyone visit my home they provided me with links, images & videos to help with breastfeeding which I found useful. My sister also had a positive experience with the team … (iHV-2020b). 134

Health visiting contacts are an opportunity to build relationships and provide reassurance

CMOC08: When assessing babies and very young children face-to-face (C) parents are potentially less anxious/more reassured (O1) because assessments are more thorough and being carried out by a trained professional (M)

Not having face-to-face visits with health visitors or midwives in the weeks following the birth, makes me anxious that she hadn’t been “checked” for any potential health concerns which may have arisen after birth. i.e. skin conditions, feeding, weight gain or loss (Best Beginnings-2020). 93

Six months on and how has my way of practising changed? It’s completely different. I’m doing behaviour visits and other contacts with parents and carers over the phone. I’ve always understood that only 7% of communication comes from the words we use. The rest is made up from intonation, body language and other non-verbal cues – that’s harder now. Perhaps the biggest challenge for me is that the child’s voice is lost. You are only conversing with a parent/carer. Over the years, I have really developed the skill of understanding what children are trying to tell me, even when they cannot yet speak. Even non-verbal children are communicating all the time. … I worry about the reduction in breastfeeding rates without any support. What is being missed with developmental reviews? (Community Practitioner-2020). 105

New mothers particularly missed the reassurance that their baby was developing satisfactorily, and that they were ‘doing a good job’. They also wanted advice on feeding, weaning and sleeping. Several women mentioned wanting to have their baby weighed, with a few recalling the drop-in clinics they had attended with previous children. Some women reported seeking informal support and information from other sources including Google, Facebook groups for parents, friends and family members with children and a few weighed the baby themselves for ‘peace of mind’. Women who mentioned this self-help approach generally said they would have preferred professional input (Jackson-2022a). 26

CMOC09: When there are fewer face-to-face health visiting contacts (C) some families will feel less supported (O) because they do not have the opportunity to build a relationship with their health visitor (M)

For many families, the increase in online support has been valuable, enabling greater flexibility and removing the need for travel time. But the risks of fully online provision have also been raised. These include challenges in identifying safeguarding issues, building positive and trusting relationships with families, and judging children’s development and parental mental health issues. Babies have been identified as being particularly vulnerable to being ‘invisible’ during online contact (Action for Children-2022). 88

Unsurprisingly, the impacts of social distancing, isolation, loneliness and an inability – or greater difficulty – in building relationships via a digital platform proved to be some of the emerging themes. There appeared to be only a few examples of families feeling as if they really knew their HV or SN, coupled with an overwhelming number of examples of families not knowing where to turn or how to contact the service for support or guidance (Halnan-2022).And further research is needed to understand their impact and any unintended consequences before any changes are adopted more permanently. The value of face-to-face work, the importance of relationships, and the significance of professionals observing a baby and parent–infant interaction must not be forgotten (Hancock-2020). 122

Remote contacts ‘work’ for certain families at certain times

CMOC10: When support is offered online (C) some families may not be able to engage meaningfully (O) because they do not have the resources or desire to do so (M)

Those experiencing poverty, chaotic homes or more significant difficulties have been particularly disadvantaged, often lacking the devices, data, WiFi and/or safe, calm space to engage. Some families have thrived in the virtual space, where it is easier for them to ‘attend’ appointments. Many young parents find the increased use of WhatsApp and other text or video-based services familiar and welcome (Best Beginnings-2020). 93

Particularly noticeable is the reduction in services for new and expecting mothers, there has been a dramatic decrease in pre- and postnatal check-ups, including the removal of regular appointments to check the baby’s health and weight. Some appointments, including check-ups for women in their third trimester (usually weekly) have been moved online, although there are certain measurements and checks that cannot be taken remotely. Moreover, women without access to devices or smartphones are left at a serious disadvantage here and mother and baby’s health will suffer as a result. In-person services at hospitals, including newborn hearing screening, face considerable backlogs and some new parents are falling through the cracks (Bear-2020). 92

Digital exclusion also remains a concern, with low-income families more likely to lack the equipment or connectivity to enable engagement with digitally delivered services and, therefore, most likely to miss out on care and support. […] Although digital service delivery may have worked as a back-up during the pandemic, this should not be confused with it being a sustainable delivery mechanism in a different context. As Action for Children have observed, during the lockdown families had fewer distractions and therefore more time to commit to services, alongside more reasons to seek support – increased engagement in services that pivoted to digital delivery at this point may have reflected these wider factors, rather than the change in delivery mechanism (Best Beginnings-2021). 94

CMOC11: When Health Visitors judge it is appropriate (C) they may use remote connections (O) because this is a way to keep in touch with all their case load in a safe way (M)

For many families, the increase in online support has been valuable, enabling greater flexibility and removing the need for travel time. But the risks of fully online provision have also been raised. These include challenges in identifying safeguarding issues, building positive and trusting relationships with families, and judging children’s development and parental mental health issues. Babies have been identified as being particularly vulnerable to being ‘invisible’ during online contact. Our own report with the Early Intervention Foundation in June 2020 explored some of the benefits and drawbacks of virtual delivery (Action for Children-2022). 88

One of the biggest changes has been the delivery of contacts, which have changed from being face-to-face, often in the family home, to either virtual or telephone contacts for both the safety of professionals and families. The iHV has published advice on the use of virtual contacts (iHV, 2020b). 134

The benefits are that it is a good option for families who are shielding, and it reduces travel time, especially in more rural locations where health visitors have a large geographical area to cover. However, there are recognised limitations to virtual contacts in relation to effective assessments of needs and risks, as well as accessibility to virtual methods and the choice of families, who prefer to have a telephone consultation rather than a virtual one (Boddy-2020a). 70

The iHV found (2021) 88.6% of practitioners agreed or strongly agreed that video enabled contacts can be used effectively to provide families with quick access to straightforward concerns. […] However, there continue to be safety concerns with the majority of practitioners reporting that video contacts could not safely or effectively replace in-person universal assessments (Boddy-2022). 99

CMOC12: When health visiting teams use remote connections to maintain an open and responsive channel of communication with parents (C) parents feel supported (O) because they feel somebody is taking an interest in them (M)

One of my successes has been the ability to give far more time to breastfeeding mothers and to help with feeding issues. A great deal more video or phone contact has been possible and just to offer a call can be very reassuring – a mother or father can feel that someone has remembered them (Community Practitioner-2022a). 109

Most positive was the experience frequently described that some families appeared readier to engage and to speak frankly remotely, and that meetings could become more collaborative and less fraught. Similarly, some young people seemed to access services – including mental health services – more readily remotely and to find disclosure easier on the phone or online. A ‘mixed economy’ (independent chair) of direct and virtual engagement was seen as the way forward (Driscoll-2020). 113

As the pandemic developed, innovative solutions emerged to support families with breastfeeding, including the use of telemedicine. Effective telehealth requires planning and proactive participation and, throughout the pandemic, it enabled families and specialists to connect (Boddy-2022a). 100

Consider offering families a 9-5 health visitor telephone advice service, if not already available, as many families are suffering heightened anxiety and are unsure how they can get the essential information they need, when they need it (Welsh Government-2020). 185

Connecting families with other services is an important part of the health visitor role

CMOC13: When there is closure of other local services/groups/organisations that health visitors can refer families to (C) health visitors cannot perform a vital part of their role (e.g. signpost/refer onwards) (O) because they have limited access to do so (M)

Many walk-in baby clinics have now closed, which cuts off another route for health visitors to offer advice and identify families that might need more support or a new parent who is struggling with mental health (Wilkinson-2022). 186

With partners working outside of the home, and mothers unable to physically meet friends, family or wider support networks, the emotional, educational and household burdens were often exacerbated. […] Particularly for new mothers, Post Natal Depression (PND) and other mental health concerns have not been met with support. There was very little support from local council-run family centres, or any other formal institutions after six weeks. At this stage, mothers have been discharged from active Midwife care and Health Visitor checks. […] The lack of kin support networks affected many new mothers’ ability to care for themselves and virtual support was not as readily available or easy to access. For instance, breastfeeding clinics online were less accessible than going to the family centre to meet with a clinician or asking a grandmother or friend for advice or help. Local council support was seen as a gap in institutional care capacities (Bear-2020). 92

In our interviews, one parent felt strongly about the reduction in open-access, baby and toddler-type groups he had noticed in his local area. The children’s centre he had attended regularly with his older daughters for Stay and Play sessions has since closed, so he was unable to access it with his third daughter. He felt that nothing had replaced this in his local area, saying that there is now a ‘definite lack there’, with ‘nothing, no similar type of free service or support available’. Even without taking account for the pandemic, he felt that ‘there’s been a complete lack of those services’ (Action for Children-2022). 88

CMOC14: When there is closure of other local services/groups/organisations that health visitors can refer families to (C) health visitors will potentially feel compelled to do more ‘extracurricular’ tasks (O) because they feel professionally obliged to do so (M)

While the health visiting service attempts to continue as normal, local community groups and services have closed their doors and moved to telephone appointments, yet many do not provide interpreting services. Over the past 10 weeks I’ve contacted emergency dentists, registered children at school, walked to pharmacies to collect prescriptions, and arranged various appointments on behalf of families (Community Practitioner-2020). 105

Emma Carey (featured on our front cover) won the NHS England sponsored Community and General Practice Nursing category of the 2021 RCN Nursing Awards for going above and beyond to support isolated families. Seeing first-hand how COVID-19 lockdowns were affecting babies and young families inspired her to create a walking scheme for health visitors and families, and a community recipe book, Bites from the Breadline, for those on low incomes. The walking group aimed to replace the informal contact, support and advice parents usually got from drop-in clinics, reduce social isolation and improve mental and physical well-being. It meant health visitors could go out to meet people, deliver public health messages and chat to parents. Everyone had access to green spaces and exercise (Sylvester-2022). 68

The Institute of Health Visiting (iHV) developed the Emotional Wellbeing at Work (EWW) programme to support health visiting services to deal with the increased demands placed on them during the COVID-19 pandemic (Baldwin-2022). 91

CMOC15: When there is closure of other local services/groups/organisations that HV can refer families to (C) families may become concerned that some of their chid(ren)’s development may be affected (O), because they are unable to socialise with other children and access different activities (M)

‘My 4 months old has only seen his brother, father and my face. I’m worried about his development also, I planned to take him to various classes, meet other mums with babies – this is also not possible at the moment’ (Best Beginnings-2020). 93

Parents are struggling to access baby and toddler groups. Our research, like others, found that many services remain unavailable for parents and their babies. Several parents told us baby and toddler groups aren’t operating or are not operating as they normally would. Even if groups are running, restrictions and booking systems make it hard for parents to access them. The flexible, drop-in nature of these groups was a key part of what made them attractive and accessible for parents and their babies. The absence and/or inaccessibility of community baby and toddler groups is likely to continue to exacerbate feelings of loneliness and isolation that have been reported over the pandemic. […] Professionals in our survey made similar observations; only 12% of respondents told us that baby and toddler groups in their area were ‘back to normal’ and 66% reported they were operating with some restrictions. Worryingly, 12% of respondents said baby and toddler groups were no longer operating in their area (Best Beginnings-2021). 94

Many parents were concerned that their babies were missing out on developmental opportunities through these classes and groups. We were reassured by both the Institute for Health Visiting and Professor Elizabeth Meins, a developmental psychologist and professor of psychology from the University of York, that it was nurturing interactions with their caregivers that contributed the most to baby development. However, the groups are still valuable, not least because of the support and interaction they provide for parents (House of Commons-2020). 43

Connecting with other health visitors is important for staff well-being and development

CMOC16: When HVs have reduced informal contact with other HVs and clinicians (e.g. with social distancing or online working) (C) they are under more stress and isolation (O) because they have reduced opportunity for informal discussion, feedback, and debriefing within HVs, and between HVs and other colleagues (e.g. GPs).

COVID-19 has made informal support from peers (in the office/over lunch) almost impossible and this is one of the hardest things to deal with over the last 6 months especially being a newly qualified HV (iHV-2020c). 135

This has been tremendously challenging, with 75% of health visitors reporting an increase in stress as health visitors have had to adapt to a very different way of working, often in isolation from colleagues as office space capacity is reduced for safety (Boddy-2021). 98

The alarm goes off for another day out in practice. I don’t actually start until 8.30 a.m. and, with no office to drive to, working from home can feel odd and tiring. I’m getting up earlier than I am used to for my 12-hour shifts in the hospital as a midwife. […] I wish we could be working together in the office and car sharing to visits. Being separate has brought home how much learning gets done talking things through on the car ride. […] It has been challenging to go from the office, with lots of informal peer support, to more lone working, which can make the role feel isolating at times. […] Team meeting: we meet online for 15–30 minutes every day to check in, catch up and talk about our day. With more remote working it’s important to ensure there is a plan in place so all whereabouts are known at the end of the day (Nursing children and young people-2021). 163

Remote delivery and home-working can affect workforce health and well-being. Risk of burnout can be mitigated by: ensuring staff have ‘down time’ between contacts to process information, adequate supervision and services do not set unattainable targets based on any disproportionate calculation of clinical time to be saved from virtual interventions. Look after yourself and follow the Government’s COVID-19 guidance on social distancing and self-isolation as needed and employ strategies which help you manage your own mental health and well-being during this time (iHV-2020n). 145

CMOC17: When HVs have the option of using online meetings to work or train with colleagues and other health and care professionals (C) this can save them time (O) because they do not have to travel to these (M).

As well as the switch to phone and video therapeutic work, The Little Minds Matter: Bradford Infant Mental Health Service have recognised the stress facing families, and have worked at pace with local partners, like Public Health, to create a video to help parents who were struggling to care for a crying baby which has been widely accessed via social media. Connecting with other professionals has continued, virtually. For example, in June they ran a webinar with an international expert, attended by over 200 people (Best Beginnings-2020). 93

The virtual world we now live in has opened up new channels of communication. Previously, it was difficult to access individuals who could support and help with new projects and research, primarily because arranging face-to-face meetings was almost impossible. With the popularity of webinars and internet meetings, that difficulty has become a thing of the past. New channels of communication are opened up, making regular contact easier and problems that might have been challenges are able to be resolved more quickly (Hanley-2021). 125

The most frequently identified benefits related to remote multiagency working arrangements, which were regarded by most participants as increasing efficiency. Attendance at meetings by professionals was frequently reported to be much higher, particularly for those such as general practitioners (GPs) who had previously struggled to take time out of clinics to attend child protection conferences and for professionals more generally in relation to short notice events such as strategy meetings (Driscoll-2020). 113

Interagency working is an important part of the health visitor role

CMOC18: When multi-agency working was reduced and outside agencies closed (C) health visitors struggled to safeguard children (O) because there were fewer opportunities for children to be seen and assessed (M)

Many professionals expressed a renewed recognition of the fact that the families who need extra help are not always the ones ‘on the list’. Efforts to engage all families during lockdown allowed professionals to identify and respond to the needs of families with babies not previously known to services, and many would like to see the role of universal and open-to-all services reinvigorated for this reason. In some areas services are already actively pursuing this, for example making additional health visits (which go beyond the mandatory checks) and bolstering programmes of open-to-all family support groups (1001Days-2021). 80

There has been talk recently of ‘ghost children’ but perhaps it is our services, not our children, who have become ghosts of their former selves. The pandemic – on top of years of austerity – has led to the withdrawal of many services from our communities. As a result, many young children do not see public services, and their needs and vulnerabilities are not known (1001Days-2022). 77

‘We are being asked to flag families that are Child Protection, Child in Need and also “cause for concern”. This is so the skeleton team left after redeployment can prioritise these cases. This seems an impossible task as our assessment of these families is only a reflection of how things stand at the time, and isn’t robust enough in a fast moving situation. Also we have no tool to inform this decision making, so it’s unlikely to be applied consistently throughout the service. What if we haven’t highlighted a family as a cause for concern and they spiral into crisis? Who will be accountable and what organisational risk assessment is in place to help protect us?’ […] ‘Those vulnerable children, now shielded from the eyes of early years provision and schools, are the ones we strive to make contact with. When the parents of these children decline our support (citing the need to be in isolation) the judgements we are forced to make weigh heavily on our shoulders’ (iHV-2020). 132

Health visiting should be valued appropriately for its impact on child and family health

CMOC19: When some of the health visitor workforce is moved into other roles (C) this leads to increased service delivery challenges for the remaining health visitors (O1) and a feeling of HVs being devalued (O2) due to increased workloads when HVs are already spread thinly (M1) and when HVs are seen as dispensable and able to move to other roles (M2)

…for God’s sake, you’ve got to give us credit, we are the people on the frontline. I’ve got really helpful information, I see clients and I see them regularly and I feel like people… yes, I feel a bit dismissed sometimes (De Backer-2022). 112

The COVID-19 pandemic has resulted in a crisis in the NHS and Social Care, unlike anything experienced before. This crisis has been acutely felt in Public Health Nursing (PHN) where large numbers of the workforce were prepared for redeployment to inpatient physical health wards to help care for the influx of patients suffering from COVID-19. […] Approximately 30% of the PHN workforce were assigned for redeployment or were self-isolating in recent weeks, with additional staff prepared for redeployment to help manage the predicted peak in hospital admissions (iHV-2020b). 134

‘I realise other services are struggling but I really worry about these vulnerable children, hidden away in dangerous homes, away from professionals who safeguard them. I will support other services but are the families on my caseload now insignificant?’ (iHV-2020)132

CMOC20: When the response by policy and decision makers to COVID was focused on short term acute issues and not longer-term public health support (C), this led to health visiting and younger children being largely ignored for policy and funding decisions (O) because they were not considered a priority (M)

We have identified three specific policy calls for the UK Government: The UK Government must support local authorities to invest in and rebuild health visiting services; Babies and the services that support them must be included in COVID-19 recovery policy and investment at a national and local level. This must include investment in community and voluntary sector support; An evidence-based approach must be taken to ensure the appropriate use of digital and phone-based service delivery, and investment in relational, face-to-face support where this is needed (Best Beginnings-2021). 94

Despite the huge pressures the pandemic has placed on families with young children, the Government’s immediate response to the current crisis has shown that 0–5s are forgotten or an afterthought (Action for Children-2020a). 78

Until recently, children in the UK have been considered inconsistently throughout the pandemic. […] During the pandemic, I have been concerned that the plight of children has been overshadowed by the Government and media spotlight being mostly on adult deaths and efforts to reduce the rampant spread of COVID-19 amongst the community. Little attention has been given to babies and young children – did most people assume they were unaffected? (Kombe-2020). 152

CMOC21: With the HV service close to breaking point pre-COVID (C) there were negative consequences for staff, families, and children during the pandemic (O) because it did not have the capacity to manage any additional pressures (M)

How did we let this happen? This state of affairs took hold long before COVID-19. It is not the failure of a single health visitor, provider or commissioner but is the predicted consequence of years of cuts to the service which the pandemic has only made worse. Councils in England have seen a reduction of £700 million in real terms in public health funding between 2014-15 and 2020-21 (Morton-2021). 158

This report focuses on the impact of COVID-19 on families, but many of the problems discussed existed before the pandemic (Best Beginnings-2020). 93

Child health in England was already at crisis point, and research has identified that the pandemic changed the way that people live and access health care (Boddy-2022a). 100

I start documenting the day’s visits and think about the referrals I did not get done this morning that I need to do. The need is high at the moment and we work hard to ensure that all families are seen, and their support needs are assessed – every family that we miss is a family that may need help, support and signposting. We desperately need more health visitors to be able to do our job to the best of our abilities, to build relationships and to identify concerns as early as possible so we can put in interventions to help families (Nursing children and young people-2021). 163