Health visiting services on ‘knife-edge’ as systematic cuts take toll

Dr Cheryll Adams, executive director of the Institute of Health Visiting (iHV), said an extra 5,000 to 6,000 health visitors were needed to be able to “deliver against the research” for early years care.

“There’s a very, very urgent need to invest”

Cheryll Adams

She cautioned that gaps in services were already leading to more children going into care and more growing up with mental health problems.

“The service is on a knife-edge, it has been for about 18 months,” Dr Adams told Nursing Times

It comes as new figures from NHS Digital show that the downward trend seen in health visitor numbers in recent years has now reached a new low.

As of January 2019, there were 7,694 health visitors in England, a fall of 25% since their peak of more than 10,000 in 2015, when a perfect storm struck the profession.

That year saw the end of the government’s successful “health visitor implementation plan” to significantly boost staff numbers, and was also when commissioning of health visiting transferred from the NHS to local government. 

cheryll adams

cheryll adams

Cheryll Adams

Since then, budgets from central government to local authorities to deliver health visiting and other core public health services has fallen year-on-year, from £3.4bn in 2016-17, to £3.134bn in 2019-20.

In addition, new training places for health visitors were reduced by 22% in 2015, according to the Local Government Association.

The latest figures show that the workforce figures have hit the lowest level since September 2012. 

However, the government insisted that the outlook was not as bad as the figures portrayed because they only included health visitors employed in the NHS and excluded primary care.

It said it was exploring ways to get better data on the workforce.

Significantly, as part of the NHS Long Term Plan, the Department of Health and Social Care is considering whether the NHS should take back some control in the commissioning of health visiting.

Dr Adams claimed that unless the commissioning model changed “there won’t be a service”.

She said the fall in health visitors was the result of both local authorities having to cut roles due to financial constraints and staff leaving, because of the pressures.

“What you’ve lost are senior, very skilled practitioners who assess hidden need before it becomes conspicuous,” said Dr Adams.

“What is happening now is that they are managing conspicuous need and safeguarding, and we know more and more children are going into care, so that situation is going to continue,” she said.

“Chronic shortages mean more health visitors are retiring early”

Fiona Smith 

Dr Adams said the shortfalls in services were also resulting in more children developing mental health issues, more being taken to A&E, and more using general practitioners inappropriately.

“It’s not about to start to happen, it’s happening now,” she cautioned. “There’s a very, very urgent need to invest.”

The challenges were also taking their toll on staff on the ground, said Dr Adams, noting that sickness rates among health visitors were “climbing steadily” and that some were leaving the profession as a result of the working conditions.

In England, mothers are entitled to five mandated health checks from pregnancy to when their child reaches the age of two-and-a-half.

However, Dr Adams highlighted how the rules did not stipulate that the checks must be carried out by a health visitor, so some local authorities were relying on lower paid staff such as nursery nurses to tick the boxes.

A survey carried out by iHV in November found that 65% of families were not seeing a trained health visitor after their child was eight weeks old, she noted.

Royal College of Nursing

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Fiona Smith

And, with the government signing off on another round of public health budget cuts for 2019-20, Dr Adams said there was a “real risk” that more health visitors would be lost.

She called for urgent reinvestment in services and for more money to be committed to training and developing new health visitors.

Meanwhile, Fiona Smith, professional lead for children and young people at the Royal College of Nursing, said the “central problem underpinning” the decline in health visitors was the local authority public health cuts.

She added that health visitors should be “central” to the government’s illness prevention agenda but noted that the momentum gained through the health visitor implementation plan in increasing numbers had been “lost”.

“There is still good uptake of the health visitor service and it remains valued by parent”


“Infants, children and their families deserve properly funded, accountable services delivered by a fully staffed nursing, health visiting and midwifery workforce backed by adequate resources,” said Ms Smith.

“Chronic shortages mean more health visitors are retiring early,” she said. “With the current state of play, nurses are choosing not to pursue this career option following qualification.

“Without proper workforce planning, the situation for children and young people will only worsen,” she warned.

The RCN is calling for safe staffing legislation in England that would hold ministers accountable for ensuring there were enough staff to meet patients’ needs.

A Department of Health and Social Care spokeman said: “There is still good uptake of the health visitor service and it remains valued by parents.

“Under the NHS Long Term Plan, we will consider whether there is a stronger role for the NHS in commissioning health visitors and will work closely with local government on this,” he said