Addressing the needs of children under ‘universal’ and ‘vulnerable’ caseloads – a psychosocial case study of health visitors within an inner London borough

The health visiting service (HVS) offers preventative ‘universal’ and ‘enhanced’ services, and remains the most cost-effective method of providing early support to families to reduce inequalities and enhance outcomes for children (Department of Health and Department for Children Schools and Families, 2009). Child abuse remains an emotive subject and people are emotionally moved when they hear about a child suffering serious injury or death due to abuse or neglect by a caregiver. The blame culture is often evident in the lessons from Serious Case Reviews which investigate deaths of children known to multi-disciplinary safeguarding partnership agencies. The focus on blame means lessons are often dislodged from engaging with practitioners and organisations to enhance child-centred service, built on compassion and sensitivity (Rawlings, et al, 2014). This study seeks to explore how HVs respond to the diverse needs of children within the conflicting demands of contemporary practice which involve relationship building with children and families, meeting commissioning targets as measured in key performance indicators (KPIs) and achieving the organisational objectives of promoting safety, reducing inequality and enhancing outcomes for children. The approach adopted in the study was a three-phase process developed in a mixed methods research to address the research questions. In phases one and two, data were collected from 100 clients’ case notes using stratified random sampling methods and mixed methods to analyse the data. The case notes included were records of children who came in contact with the HVs between January 2016 to December 2016, and case notes which did not meet these criteria were excluded from the study. In phase three a quota sampling method was applied to select 20 HVs who worked in an Inner London Borough within the specified period; and were interviewed, with interview data analysed in this phase. The HVs employed via staff bank or agency were excluded from the study. The research received approval from Middlesex University Ethics (appendix 8c) and the local NHS Trust Ethics Committees. The key finding of this research is the significance of client-professional relationship which emerged as the overridding factor influencing child and family assessment, needs identification, engagement with services that enhance outcomes for children. Whilst significantly high numbers of children from Black and Minority Ethnicity (BAME) background were classified as vulnerable compared to White children, significantly less number of BAME families was seen to access HVS compared with White families. Because of the desire to secure and develop relationship with families and address the needs of children, HVs spent a disproportionate amount of time working with vulnerable families compared to those receiving universal services. Other influencing factors include: uncertainty in defining threshold of needs and interventions, interpretations of risk and vulnerability, high work demands and low control over client’s acceptance of service offer or engagement with professionals seem to generate high level of emotions. These also raise anxiety among HVs which provoke practice that tends to suggest defensiveness and paternalism towards families. The key finding of this research is the significance of client-professional relationship which emerged as the overridding factor influencing child and family assessment, needs identification, engagement with services that enhance outcomes for children. Whilst significantly high numbers of children from BAME background were classified as vulnerable compared to White children, significantly less number of BAME families were seen to access HVS compared with White families. Because of the desire to secure relationship with families and address the needs of children, HVs spent a disproportionate amount of time for vulnerable families compared to those under universal services. Other influencing factors include: uncertainty in threshold definitions and interpretations of risk and vulnerability, high work demands and low control, and high level of emotions and raised anxiety among HVs and these provoke paternalism and defensiveness in practice. It could be argued that the influence of forensic approaches to addressing needs of families have driven health visiting practice to focus on risk assessment and child protection procedures at the expense of its traditional preventative and supportive work based on relationship with families thereby undermining child-centredness. The research findings have implications for health visiting practice and policy makers in seeking reasonable balance on demands from HVs to implement the national Healthy Child Programmes and responding to additional needs of children and families. The critical issues are for commissioners and managers to prioritise the emotional demands of health visiting work, and also to provide consistent supervision, reflective spaces and family-focused relationship training as the core of any approach and policy to safeguard and protect children