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Health Visitors

Volume 456: debated on Wednesday 31 January 2007

I am happy that the Economic Secretary is still with us. I shall make a point of sending him the speech that I am about to make. I shall make a number of points about the comprehensive spending review, and I am sure that he would be most interested in pursuing early intervention as an important part of that review.

I am delighted to have secured the debate, not least because it is the latest in a sequence of debates that I have held with Ministers in different Departments, all of which cover the same subject of early intervention. Ensuring that those between the ages of nought and two get the right start in life is the best sort of early intervention that we could make. In my experience as Member of Parliament for Nottingham, North and more recently as chair of One Nottingham—the local strategic partnership—the earlier we intervene the more effective we will be in tackling the symptoms that appear later in life. Those symptoms include the inability to learn and interact at primary school, the disruption of classes at secondary level, antisocial behaviour, petty criminality, drug abuse, failure to get skills and work and, perhaps most crucially, the inability to form effective social and personal relationships.

My constituency sends the fewest young people to university of any in the UK. One in eight young people cannot read the first lesson at secondary school and 58 per cent. of births in Nottingham take place out of wedlock. Breaking the intergenerational replication of those symptoms by early intervention is the key. All those problems can be traced back to the early years if the skills necessary for later social and emotional literacy and empathetic behaviour are not acquired by the youngest in our society from their parent or parents.

The home learning environment is the key to attainment, as the work of Professors Sylva and Sammons at the university of Nottingham has demonstrated and as the Chancellor of the Exchequer has generously acknowledged to them. One Nottingham and our partners will propose a coherent set of programmes to make real our concept of Nottingham as “Early Intervention City”. We will propose 12 important policies, the cornerstone of which will be effective intervention for those aged from nought to two and their parent or parents. That immense social responsibility falls on health visitors and midwives, who do an incredible job in my city. I want to dedicate my speech and our further work to them because of the fantastic work that they do.

I want the Government to understand that heroic personal effort is not the basis of a sustainable strategy. That is why the work of Professor Olds on nurse-family partnerships assumes a massive significance. I congratulate the Government, particularly the Department of Health and the Cabinet Office, on their foresight in pursuing that and putting it at the centre of the social exclusion action plan. The Government have already requested bids for 10 pilot schemes, and I understand that more than 63 organisations have applied, including the primary care trust in Nottingham. As an aside, I should say to the Minister that the project is of such importance to us in Nottingham that, if the PCT bid were to fail, One Nottingham would consider funding an identical project. I hope that, if that eventuality were to come to pass, his Department would offer us its assistance in that difficult task.

Essentially, the scheme ensures that the most deprived families will receive intensive visits from health visitors for two years. However, let us not mistake an effective policy instrument for a strategy. We need to ensure that the pilot schemes do not end their work when the initial funding runs out, but are mainstreamed. That will require appropriate capacity in the health visiting service and the consequent substantial funding that that implies. It will require many other agencies and partners to support that effort. It would be unacceptable for the long-term burden to fall on the PCT alone.

The comprehensive spending review—hence my opportunistic remark to the Economic Secretary as he left the Room—should remake that part of social policy. It is important that the Minister does not answer my questions with the statement that resources are available in the baseline—I am sure that he would not. The point is about additionality and the challenge of Derek Wanless on prevention and on securing good health for all and, remarkably, on being able to reduce the percentage of gross domestic product spent on the NHS. I have today requested a meeting with the Chancellor to discuss that and the need for an ambitious public service agreement target on early intervention.

A proper examination of health visitors’ case loads is also required. In Nottingham, they are between 270 and 435—10 times more than that prescribed for nurse-family partnerships. Nottingham has 54 whole-time equivalent health visitors for the whole city. Does the Department know how many health visitors would be needed to roll out nurse-family partnerships for the whole of Nottingham, or indeed for the UK?

I could try to make a case for health visitors, but the most eloquent expression that I have comes from a health visitor. She told me this week about the problems that need to be resolved: the lack of investment in health visitor training, as the course time was extended, which meant that the numbers of health visitors had to be reduced; the pay structure for health visitors—under “Agenda for Change”, midwives now get a higher salary than health visitors, as do ward sisters—and the fact that many nurses who wish to undertake the health visitor course are experienced nurses and cannot keep their grading if they switch to health visiting, which is already having an impact on those coming forward. It is extraordinary and perverse to drive experienced nurses away from preventive work, and I hope that the Minister can announce an early remedy.

The health visitor continued by saying that health visiting has become a Cinderella service. The work that health visitors do is preventive, and so the service is always cut when financial problems arise. No one understands what they do, and the nature of the job means that they cannot promote themselves in the same way as midwives can. They do wonderful work, but it is hidden and they have not been good at evaluating their work to prove their worth. They are now involved in immunisation clinics, which takes up many hours of their time, and case loads are too high in many areas.

The Government need to come to terms with the harsh reality that the magnitude of the early intervention needed to break the intergenerational cycle in a place such as Nottingham is qualitatively and quantitatively different from our ambitions. To put it bluntly, it has to be part of the bigger vision for society of a new Prime Minister. Patch and mend and the odd short-term pilot here and there just will not do.

All health visitors are qualified nurses or midwives with additional special training and experience in child health and health promotion and education. Every family with children under five has a named health visitor who can advise on everyday difficulties such as teething, sleeping and feeding, as well as immunisation programmes, parenting classes and managing difficult behaviour. Health visitors, properly trained and resourced, could become the means by which we intervene to end intergenerational underachievement.

Alan Sinclair’s excellent report “How Small Children Make a Big Difference” says:

“We screen all pregnant women for factors associated with the child’s health—from a clinical perspective. We ought at the same time to screen for social factors that will adversely affect the journey of the women and children.”

The nurse-family partnership home visiting programme takes that further. It was set up by Professor David Olds from the university of Colorado, and it has three key goals. First, pregnancy outcomes can be improved by helping women to practise sound health-related behaviour such as prenatal care, improving diet and reducing the use of cigarettes, alcohol and incidences of substance abuse. Secondly, children’s health and development can be improved by helping parents provide responsible and competent care for their children. Thirdly, the family’s economic self-sufficiency can be improved by helping parents to develop a vision for their own future, to plan future pregnancies, to continue their education and to find jobs.

Home visitors are highly educated registered nurses. They receive more than 60 hours of professional training from the nurse-family partnership professional development team. Nurse home visitors and families make a 30-month commitment to one another, following which 64 visits are made per family. They begin making visits during pregnancy—no later than 28 weeks after gestation—and continue through the first two years of the child’s life.

Key elements include the targeting of the programme to support at-risk families, specific training aimed at supporting parental behaviour to foster emotional attunement and confident non-violent parenting. An average of 33 visits per family are made, from the onset of pregnancy until the child reaches the age of two. Visits last on average between 75 and 90 minutes. Each nurse has a case load of about 25 families. I should not refer to the Public Gallery, but I see that that objective has raised some smiles. Those figures are a world away from health visitors in the United Kingdom, as they are rarely able to afford more than 20 or 30 minutes per visit, because their case loads are so high.

In addition to helping parents to attune emotionally with their children and to use consistent and more appropriate discipline regimes, the nurses help the mothers to envision a future that is consistent with their own values and aspirations; help them evaluate contraceptive methods, child care options and career choices; and help them develop concrete plans for achieving their goals.

Nurse-family partnership mothers are less likely to abuse or neglect their children, have subsequent unintended pregnancies, or misuse alcohol or drugs, and they are more likely to stop needing welfare support and to maintain stable employment. Among the partnerships’ striking successes are a reduction in child abuse and neglect of 50 per cent. in Elmira and a reduction in Memphis of 75 per cent. in hospitalisations due to non-accidental injuries. That 26-year evidence base cannot be denied. Compared with control group counterparts, families who participated in the Elmira trial exhibited the following successes 13 years after the programme ended. It was not a flash in the pan, and people did not say, “Let’s make it up; we think it is a good scheme.” It is fantastic evidence. There were 69 per cent. fewer arrests of low-income unmarried mothers in the 15 years following the birth of their first child. There was a 44 per cent. reduction in maternal behavioural problems due to substance use—imagine the money clocking up that is being saved. There has been a 32 per cent. reduction in subsequent pregnancies. The interval between the birth of the first and second child is now two or more years. There has been a 30-month reduction in the need for welfare. There has been an increase of 83 per cent. in employment by a child’s fourth birthday. Among the children of low-income unmarried mothers, there have been 56 per cent. fewer emergency room visits where injuries were detected. There has been a 79 per cent. reduction in child maltreatment. There have been 56 per cent. fewer arrests and 81 per cent. fewer convictions among adolescents; and 15-year-old children had 63 per cent. fewer sexual partners.

It is our ambition to give Ministers in many Departments similar outcomes for Nottingham when our nurse-family partnership has taken root. A health visitor told me this week that such a programme would

“get the service back on track again; we did this intensive visiting 28 years ago, and we were told to stop because we were making people dependent on us.”

As a result of its success, the nurse-family partnership is offered in 20 American states, and it serves more than 20,000 families annually. The programme is not cheap—it costs about $8,000 per family for two and a half years’ support. However, economic evaluation by the Rand Corporation shows a payback to the public purse of four times its cost. I believe that that could be a massive underestimate, as the positive benefits of creating happy, healthy and well-adjusted children roll forward into every succeeding generation.

The nurse-family partnership is tested and highly recommended. It topped WAVE’s evaluation system and was recommended by the Sure Start review, the Blueprint programme, Support from the Start and Communities that Care. However, the key question for Nottingham does not concern the viability of nurse-family partnerships or the success of the pilot, but the mainstreaming of the nurse-family partnership once the pilot has proved successful. When I convened a meeting of local health visitors, they all said “This is great and we’ve done it before, but it is never sustained.”

I ask my hon. Friend the Minister to consider these questions. First, what negotiations is he having within his Department and under the comprehensive spending review to prepare for successful nurse-family partnerships to be rolled out that are financially sustainable? Secondly, what measures are in hand to increase the recruitment and retention of health visitors—in particular, to increase their public profile and prestige—and, alongside that, to introduce the concept of early intervention? Thirdly, what measures are in hand to reduce the case loads of health visitors, so that they can make more effective and lasting interventions?

Without effective early intervention, we are condemned to repeat history with our deprivation and underachievement. However, with a package of effective measures, Nottingham can become “Early Intervention City”. Our ambition is not to service the cycle of intergenerational failure but to shatter it, and to give kids in Nottingham—and, we hope, throughout the UK—the life chances that they deserve.

May say what a privilege it is, Mr. Cook, to see you in the Chair again today? I spent the morning with you. I hope that hon. Members do not take that the wrong way, but you know exactly what I mean.

I congratulate my hon. Friend the Member for Nottingham, North (Mr. Allen) not only on securing this Adjournment debate but on the leadership that he is providing in Nottingham. His passion and commitment are focused on ensuring that Nottingham can truly claim the title “Early Intervention City”. That would be a first for the United Kingdom. More significantly, my hon. Friend is working to get us, at the national level, to reflect on what we really need to do to replace intergenerational deprivation with what I described when I had the skills portfolio as intergenerational advance.

Frankly, nothing could be more important than that for a Labour Government. People ask what is our core priority—what do we most want to transform in our society? It would be the greatest legacy for this Government, for as long as we last—and I hope that we will last for a long time to come—if history were to say that the policies that we put in place had genuinely laid the foundations that would help to shatter a society that is still too divided, that still has too much disadvantage and in which far too many people are still denied the economic and social opportunities that hon. Members take for granted.

May I say to my hon. Friend, in all authenticity, that he is doing a great service not only to his city? I believe that we should endorse the concept of the early intervention city, and that Nottingham should be the first such city in the United Kingdom. I hope that that will be seen as trailblazing the concept for other parts of this country.

It also makes an interesting point about the role of politicians in a modern world. Sometimes we are sucked into believing that the only way to make a difference is to attend Committees, sit around tables, and give people titles—some of which may be ministerial. My hon. Friend has demonstrated the power that can be used by a constituency MP who is willing to step up to the mark, provide community leadership and make a difference in a transformational way. My hon. Friend knows, as all politicians do these days, that we will be judged by our actions, not our words, and by the outcomes as a consequence of those actions.

The nurse-family partnership is fascinating because it is almost a missing piece in the jigsaw. The Government’s record on early intervention post-1997 is extraordinary. It is even more extraordinary that this country was so far behind in early intervention by 1997. Frankly, that was a scandal and a disgrace. In terms of our long-term economic and social interests, people often forget that, as a society, we did not even have the infrastructure or the architecture to provide early intervention, which is the most powerful thing that we can do to break the cycle of intergenerational deprivation.

The nurse-family partnerships represent the missing piece of the jigsaw, but let us look at other elements. On maternity services, we are about to produce a significant plan that will demonstrate how we will make a reality of our commitment to choice for every parent all over the country. People forget that antenatal and post-natal maternity services are every bit as important as those relating to the birth itself.

We have developed Sure Start and will be providing children’s centres for every neighbourhood and community. However, what matters is what goes on in those children’s centres; simply having them will not make the transformational difference required. This Government introduced universal nursery provision. Other countries had taken that for granted for decades, but it was this Government who introduced that in this country. Another important piece of the jigsaw is the financial support for individuals and providers. That is needed massively to expand access to quality child care.

Another missing piece of the jigsaw could be what my hon. Friend describes as social education in primary schools. That has begun in his constituency and I know that it is happening in other parts of the country. There is a case for looking at the potential to mainstream that in our education system. As a Health Minister, I am not sure I am supposed to say that so let us hope that no one is listening too closely at the Department for Education and Skills—or maybe we should hope that they are.

On the question of the bid, the number of local authority primary care trust partnerships that have submitted bids for the pilots is reassuring and exciting. It is good news that the number of expressions of interest has been as high as it is. More than 40 per cent. of partnerships have submitted a bid. I agree with my hon. Friend’s point that the purpose of the pilot is not, in this case, to see whether it works—the evidence is overwhelming on that. The purpose of the pilot is to learn the lessons to enable us to mainstream the scheme as effectively as possible.

Obviously, we are about to announce the successful bids and it would be inappropriate for me to go any further than that during this debate. The message from my hon. Friend, which has been delivered privately as well as publicly, is that, irrespective of whether this particular bid from Nottingham is successful, he intends to ensure that the programme is set up in Nottingham. The commitment that I make is that if he is able do that by pulling together the necessary commitment and resources within Nottingham, we will extend to him, and the relevant partners in that city, the maximum possible assistance to enable them to achieve their objectives. Depending on our satisfaction with the design of the programme in Nottingham, we may also—and it is only a “may” at this stage—be willing to extend the evaluation to the project that Nottingham may or may not design. However, we must not prejudge the outcome of the bidding process at this stage.

I put on record my thanks for what the Minister has said. We treat his words seriously and will not let him down on the commitment that he has just made.

I will turn to a number of other issues that my hon. Friend raised. He rightly makes an incredibly strong case for health visiting as a profession and for the distinct contribution that health visiting should and does make. We want it to make a more significant contribution in the future. It is true that, to some extent, health visiting is going through a difficult time in many parts of the country. The number of nurses in the NHS has increased by more than 85,000 since 1997 and the number working in the community has increased by 36 per cent. during that time. We can point to a significant overall increase in the number of health visitors. Undoubtedly, all too often, primary care trusts do not regard health visitors and the contribution that they make as being as powerful and important as it is.

As it has not been given much publicity, my hon. Friend is probably not aware that my right hon. Friend the Secretary of State recently announced at the Amicus health visitors conference a fundamental review of the role of the health visitor in a modern society and health service. A big part of the outcome of that review will be the role for health visitors envisaged in these pilots.

There are some difficult issues to resolve; for example, the nature of the universal service that is available to all parents and families from health visitors as opposed to more intensive, targeted support. As the Minister responsible I do not think that the nature of the service is clear. There is much work that needs to be done with the professional bodies, representative organisations and trade unions to tease that out. What is the minimum entitlement that every family has a right to expect from the health visiting service wherever they live? In addition, what is the offer? Will it be focused around the model and the partnerships outlined in the work of Professor Olds? We have to resolve that issue as part of the review.

I reassure my hon. Friend and others that we understand that health visiting is at a crucial point. We need to look at the interface between health visiting and other professions. As completely different professions develop and emerge, we want to encourage much closer working relationships between people irrespective of their professional titles or job descriptions. We need to consider how to get maximum gain from health visitors, midwives, maternity support workers, mentors and the range of professionals who are out there trying to do their best to—as my hon. Friend described it—break the cycle of intergenerational deprivation. How do we bring all of that together in a maximum powerful way? In that context, we must recognise the distinct professional expertise and background that health visiting has to offer every community, and the review will be important in relation to that.

My hon. Friend also asked about mainstreaming the resources and the comprehensive spending review. The Economic Secretary would not forgive me if I gave anything away, but he is absolutely right to say that we must plan ahead—his predecessor would have taken a similar view. The evidence is already there and if these pilots are successful, it would be a shame to have to wait four years before we can expand them. The guidance that we give to commissioners in the health service and local authorities is another vehicle by which we could insist over time that this cross-government outcome on early years prevention and intervention becomes one of their priorities. Therefore there are other levers available.

My hon. Friend also asked about the case load of health visitors. That is part of the review and the consideration in terms of a universal service as opposed to an intensive and targeted service. Clearly, the nature of the service determines what is a realistic case load to take on to add true value and make a real difference, rather than having a superficial relationship with people that is not able to create the changes that we want.

There are many exciting things happening: the pilot, the plan to deliver maternity choice, and the review of health visiting. We need to ensure that that all comes together and contributes towards the missing piece of the jigsaw in terms of early intervention. In the end, it is about breaking that cycle of intergenerational deprivation—

It being Five o’clock, the motion for the Adjournment of the sitting lapsed, without Question put.