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Open access fifty years on: reflections on research on the role of the health visitor, june clark dbe, frcn, faan, professor emeritus, swansea university, wales.

The 1960s and 1970s were exciting times for me on a personal and professional level. My personal and professional lives became inextricably intertwined. In 1962, I graduated with a degree in classics from University College London. I had already decided, much against my parents’ wishes, that I wanted to be a nurse.

Nursing Standard . 35, 10, 15-18. doi: 10.7748/ns.35.10.15.s23

Published: 30 September 2020

As a student nurse I was already regarded as ‘a bit of a troublemaker’ and I became active in the RCN. In 1966 I got married and our children were born in 1969 and 1972. In 1967, I qualified as a health visitor and went to work in Berkshire, where my husband held a university post and we lived on the campus in a university flat. These seemingly irrelevant factors determined the next ten years of my career including, in particular, the development of my research into health visiting.

This study of health visiting in Berkshire was my first attempt at research and was also one of the earliest studies undertaken by any nurse in England. This early study is the focus of my contribution to this RCN Fellow’s 2020 publication, nearly 50 years later.

The role of the health visitor: a study conducted in Berkshire, England

A study of 1057 home visits undertaken by health visitors in Berkshire in 1969 showed that the range of the health visitor’s work was much wider than the stereotype which portrays health visiting as an activity limited to maternal and child welfare and concerned mainly with physical care. The sample was the population of health visitors, 82 in all, employed by Berkshire County Council. The health visitors completed a questionnaire, were interviewed, and recorded their home visits for one week. Seventy per cent of the visits were to households containing a young child, 18% were to the elderly, and 12% to other households. The content of the visits was recorded in terms of the topics discussed. Some topics were essentially medical, and some were within the scope of the stereotype, but many were topics not traditionally associated with health visiting and there was a considerable psychosocial content. Differences were found between visits recorded by younger and recently qualified health visitors and visits recorded by other health visitors.

Clark J ( 1976 ) The role of the health visitor: a study conducted in Berkshire, England. Journal of Advanced Nursing. 1, 1, 25-36. doi: 10.1111/j.1365-2648.1976.tb00425.x

onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2648.1976.tb00425.x

Introduction and background

The 1970s were turbulent or exciting times, whichever way you looked at them. The National Health Service (NHS) was embroiled in preparations for its major reorganisation in 1974 which involved the transfer of community health services, including health visiting, from local government to the newly created health authorities. I was appointed as the nurse member of the Berkshire Area Health Authority, which enabled me to become deeply involved in the development of health and social policy, working with many of the leaders in health care of the day. In 1962, the Health Visiting and Social Work (Training) Act had established the Council for the Training of Health Visitors (CTHV), later extended to include education (CETHV) as the new regulatory body for health visiting. The council established several working parties that attempted to define the future role of the health visitor, and in 1966 a training programme with a new curriculum had been introduced, designed to produce a ‘new breed’ of health visitor with a much broader role ( Clark 1968 ).

I was one of the first to qualify under the new regime. The decade also included the Committee on Nursing (Briggs report) ( HMSO 1972 ) and the 1979 Nursing, Midwives and Health Visitors Act, which replaced the General Nursing Council with the UKCC and abolished the CETHV. The NHS, nursing, and nursing education were turned upside down. Other issues of the day were the development of the primary care team and the attachment of health visitors to general practice, both of which were controversial and were seen by some as a challenge to the autonomy of health visitors. There was tension between health visitors and social workers and the role and status of health visiting was continually challenged.

Already active in the RCN, I found myself involved in numerous working parties and a speaker at numerous conferences. At home with two babies I had the flexibility to serve on lots of committees and task groups. I published articles in the professional press with titles such as That uncertain knock on the door, No new type of visitor, What do health visitors do? The dilemma of identity in health visiting.

I became the health visiting consultant to a popular newsstand publication called Mother and Baby, even acting for several years as the magazine’s ‘agony aunt’. I often thought that I did more and better health visiting in this role than I ever did by knocking on doors – it certainly shattered my complacency about how wonderful health visitors were. I was becoming well known as a ‘champion’ of health visiting.

The trigger for action was the publication of the Report of the Committee on Local Authority and Allied Personal Social Services, The Seebohm Report, in July 1968 ( HMSO 1968 ). The report specifically excluded health visitors from its membership and considerations and stated: ‘In our view the notion that health visitors might further become all-purpose social workers in general practice is misconceived’. It recommended that a new Social Services Department should be set up in each local authority which would undertake the existing work of the children’s department, the welfare department, and parts of the health department. Functions that health visitors had traditionally regarded as theirs were transferred to social workers who would exercise a central role in the new system.

Social workers were delighted but health visitors were furious. They complained that they had been misunderstood, misrepresented, and undervalued. I agreed and stood up on several conference platforms to say so. But I argued that if people did not understand what health visitors did, it was probably because health visitors had not told them. There was a plethora of opinions and recommendations about what the role of the health visitor should be, but a dearth of factual information and evidence about their actual practice. What was needed, I argued, was some proper research.

But who could do the research? At the time, nursing research in the UK was embryonic. There were a few studies using work study methods undertaken by researchers who were not health visitors, which health visitors rejected as contributing to the misunderstandings. Very few nurses or health visitors had a first degree, which was the normal university requirement for undertaking post graduate research.

Almost none had a doctorate, which meant it was very difficult to find nurses who could supervise nursing doctoral students. My husband’s job precluded a move to one of the developing epicentres of academic nursing such as Manchester University. I knew nothing about research methods, and I searched in vain for some kind of course that my family commitments would allow. The mantra of the Briggs Committee on Nursing that ‘Nursing should become a research-based profession’ was still four years in the future ( HMSO 1972 ).

But I did have a first degree, I was living on a university campus, and I was ‘unemployed’ because I was pregnant or occupied with babies. My RCN involvement brought support and mentorship from some wonderful nurse leaders such as Marjorie Simpson, Jean McFarlane, and Grace Owen, who were planting the ‘little acorns’ of nursing research which later grew into oaks. I obtained a grant from the King’s Fund – the first one ever awarded to an individual nurse. I joined the fledgling RCN Research Discussion Group. Professor Peter Campbell, Professor of Politics, and Dr Viola Klein from the sociology department at Reading University agreed to take on the formalities of my registration for a MPhil. At the time, most master’s degrees were research-based degrees rather than taught programmes.

I was introduced to Professor Margot Jefferys, one of the founders of the developing discipline of medical sociology, who encouraged me and became my external examiner. And there were other benefits. I had tremendous goodwill from the health visitor interviewees, and I discovered that being accompanied by a breast-fed baby established an immediate rapport in interviews! I sent a questionnaire to every health visitor in Berkshire, achieving a response rate of 89%; I interviewed 79 health visitors and persuaded 72 to record all their home visits for a week using a recording form that I devised, amounting to 2,057 visits in all.

The interviews were recorded on a reel to reel tape recorder the size of a suitcase. The data was analysed using the (then) new Reading University computer which filled a whole building. The thesis was typed on an old-style typewriter with carbon copies – it was more than a decade before computers and word processing came into common use. In 1972 I graduated with the degree of MPhil. The thesis, suitably edited, was published in book form in 1973 under the title A Family Visitor ( Clark 1973 ) – the first in the series of research monographs published through the 1970s by the RCN in conjunction with the Department of Health and Social Security (DHSS). I participated in a BBC series of television programmes about primary health care ( Bloomfield et al 1974 ), and I spoke at many conferences at which my study was referred to. The study was also published as a series of three occasional papers in the Nursing Times, the newest outlet at the time for academic articles about nursing. The 1976 paper revisited for this article was published in the first issue of the Journal of Advanced Nursing.

Impact and influence

This study was undertaken nearly 50 years ago. The health visitor of the 1960s would hardly recognise health visiting as it is today. The ‘family visitor’ with a caseload that includes people of all ages appears to have become nowadays largely a protocol-driven system of developmental checks on young children – an important function, but not the only one. Health visitors no longer visit older people, and family support is seen as the function of the social worker.

In 1999, I was commissioned by the Welsh government to undertake a review of health visiting in Wales The review found that the number of health visitors in Wales had declined dramatically during the previous decade, that the introduction of general management following the 1983 Griffiths report had diminished the position of the heath visitor in the organisational structure and led to the loss of professional leadership ( Clark et al 2000 ).

The review contained several recommendations, but the report was quietly shelved. The good news, however, was that some of the local directors of nursing supported the report and quietly implemented several of the recommendations within their own management arrangements. Fortunately, during the past decade, perhaps as a result of the renewed importance of public health in government policies, health visiting appears to be experiencing something of a resurgence.

My increasing profile in health visiting and primary health care during the 1970s led directly to my representing the UK in work with the International Council of Nurses and the World Health Organization (WHO) following the WHO Declaration of Alma Ata on Primary Health Care in 1978 and the WHO Global Strategy for Health for All by the Year 2000. My search for others who were researching in the same field led me to Professor Sirkka Lauri in Finland, which I visited on a Council of Europe Fellowship in 1981 and several times subsequently. What I saw in Finland revolutionised my ideas about health visiting and primary health care. I published more articles and spoke at more conferences, but sadly, my proposals – such as visiting by appointment, structured documentation, sharing records with clients, seemed ahead of their time. At that time, they were not popular with UK health visitors.

Now, they are recognised as central to good practice. The Department of Health’s continuing search to understand health visiting practice ( Clark 1982 ) led to a new research project to develop a model for explaining health visiting practice which eventually became my PhD ( Clark 1985 ), and a project to identify the outcomes of health visiting practice ( Clark and Mooney 2001 ). Citations in other people’s work continued well into the 1990s. In 1982, when I was elected Fellow of the Royal College of Nursing, the citation said, ‘for her contribution to the art and science of nursing in the field of health visiting’.

But I can hardly claim that the study itself had any influence on the developments in health visiting in the 1970s, which were largely determined by the introduction of legislation and other external events over which the profession could exercise little control. In particular, the absorption of health visiting into the new framework of the 1979 Nurses, Midwives and Health Visitors Act moved health visitors from having a unique title and professional registration which was mandatory for practice, to recordable with the Nursing and Midwifery Council as ‘specialist community public health nurses’ alongside a variety of other nurses with no such requirements. Midwives retained their specialist identity; health visitors lost theirs. With hindsight, the legislation of the 1970s could be considered as marking the beginning of the demise of health visiting as I had known it.

Current and future relevance

It is hard to think that my research of some 50 years ago might have relevance to current and future researchers or practitioners, but it continues to be cited from time to time. Perhaps, however, any influence I might have had applies more to individuals than to big changes in policy. The outcome of which I am most proud is the number of individuals whose careers I was able to help, many of whom are now the leaders of the profession, just as the great nursing leaders of the 1960s and 1970s supported me. Health visitors I meet at conferences and other meetings often recognise me, and the older ones, that is, my contemporaries in health visiting, who are now, like me, approaching their eighties, often refer to my work in health visiting and in particular to this study. I did not know whether to be flattered or horrified when I discovered quite recently that A Family Visitor was still included in some students’ reading lists!

As my children grew up, I expanded my interests into other fields of nursing – care of older people, nursing education, and standardised nursing terminology for electronic patient records. I am no longer directly involved in health visiting, but with hindsight I can see some relevance of this study to my and others’ later work in other fields. I have been fortunate to be able to combine practice, research, and teaching in my long career ( Clark 2016 ). With hindsight I can see that the methodological approach of trying to capture the essence of health visiting practice through identification and recording of the topics discussed in the home visit, as described in this paper, led directly to my work on the development of a standardised terminology to capture the essence of nursing, the International Classification for Nursing Practice ( Clark and Lang 1992 ), and to make nursing and health visiting visible in electronic patient records. Only now in 2020 do I see the beginnings of understanding among nurses why the use of standardised terminology and structured documentation for nursing practice is important.

Fifty years later I still carry and promote the attitudes and ideas that were born in my health visiting days – the focus on prevention and early intervention, the social determinants of health, public health as opposed to individualised ‘treatment’. The principles of health visiting which were set out in the 1970s ( CETHV 1977 ) apply equally today and to every field of nursing:

» The search for health needs

» Stimulation of awareness of health needs

» Influence on policies affecting health

» Facilitate health enhancing activities.

Health visiting still has much to offer in meeting society’s health needs.

Correspondence

[email protected]

Open Acesss

This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International (CC BY-NC 4.0) licence (see https://creativecommons.org/licenses/by-nc/4.0/ ) which permits others to copy and redistribute in any medium or format, remix, transform and build on this work non-commercially, provided appropriate credit is given and any changes made indicated.

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We actively promote and support high quality research to drive forward improvements in health visiting practice and health outcomes for babies, children and families. Every health visitor has a part to play in health visiting research and developing excellence in practice.

The NMC Standards expect that:

Specialist Community Public Health (SCPHN) Health visitors, locate, critique, use, generate and apply evidence, data and information that seeks to promote health and prevent ill health and disability from life choices, environmental factors, non-communicable diseases, trauma or other health conditions. They evaluate public health interventions to better understand what works and what may need to change and why. They propose new and innovative ideas and concepts to inform and improve the health and wellbeing of people across the life course and apply an evidence-based approach to optimise public health programmes and interventions.

This expectation applies to health visitors throughout the UK. We share the ambitions set out in the Chief Nursing Officer’s strategic aim for research in England:

to create a climate where nurses are empowered to lead, use, support and participate in research as part of their job, where the voice of the profession is valued and impacts on conduct, leadership and translation of research.

We aim to amplify the voice of health visitors and the babies, children and families we work with across the UK, so that ‘leading, delivering and supporting research is valued and embedded in the everyday practice of health visitors’.

We do not directly fund research but work in collaboration with universities and other organisations as partners in research . We aim to support research training and opportunities for health visitors to undertake research, develop their skills and support career development in research.

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Writing a research proposal

The format of a research proposal varies depending on what or who it is required by. They can vary in length, ie. be very concise or quite long and detailed. Also the headings for the different sections can vary.  Therefore, this guide deals with the research proposal in its most generic form, which should be easily modifiable to fit the criteria for any research body.

The ultimate aim of any research proposal is to convince people that your research is important, has not been done before, is worthwhile and is feasible. Hence you have to make a strong argument for your research. The language used should be clear and easy to understand, as often non-experts will assess it.  Some funders may, and the Research Ethics Committee application form will, want a ‘lay’ summary in addition to your basic proposal document.  It is usually only in the background and methodology sections that writers tend to assume that the intended audience has a particular knowledge of their research area.

 Additionally, it is crucial that different sections of your research proposal should link or follow on from each other, eg. the research question should link with the methodology.  This may sound obvious, but revisions of one section can lead to mis-matches. Check this before submitting your proposal! 

Typical stages in a research proposal

1. The purpose of a research proposal is:

• To help to focus on a relevant and current topic.
• To identify a gap or inadequacy in the research literature.
• To make sure that these are your ideas, and to help you to focus and crystallise your ideas.
• To help you to focus on what the actual stages involved in the research process will be, eg. the exact methodology and data analysis that will be adopted.
• To justify a proposed research project to a particular audience, eg. supervisor, departmental or faculty committee, external funding body etc.

2. Some strategies before you start:

• Search through literature for topic related articles and books, ie. search through databases/catalogues/journals etc.
• Look at what is already being done in the area i.e. existing data and research.
• Read critically, ie. look for interesting and suitable gaps – areas for research.
• Talk to your employer for approval – there is no point in starting research that you will not be allowed to complete.
• Talk to your local research and development teams.  They will be able to tell you the specific criteria for any research proposal and may highlight some issues that you have overlooked.
• Talk to experts or supervisors in the field – in person, phone, letters, e-mail.
• If it is helpful, use concept maps to link ideas, and or formulate questions that the literature review should address. 

3. Identifying your research question:

Any research proposal needs to have a clear research question for it to succeed.  Without a clear question research will become confused and lack direction. Subsequent analysis will be difficult because the research question is key to forming your hypothesis or aims, and later analysis.

Do start by writing a question, not a statement.  This will help clarify exactly what the issue is that you are trying to find a solution to.  Hypotheses, aims etc can then follow from this.

Your research question should:

• Be as clear and concise as you can make it.  Don’t use multi-barrelled questions if you can avoid them.
• Be informative – state your population of interest, locality etc.
• Avoid technical jargon – this is the golden rule in most areas of research proposals.  Remember that your research question is what will capture the interest of the reader / assessor.
• Relate to the proposal title – often the research question is quoted as the title of the proposal.
• Relate to the aim of the research – again, the research question is often quoted as the research aim.

It should be obvious from your question alone what the project will aim to do, and on who.

4. Project title:

The title should be brief but informative. It is important that it is clear and easy to understand, and describes what your proposed research is.  As previously stated, this is often the research question.

5. Abstract or summary:

This is a very important section which bears a disproportionate share of responsibility for success or failure of a proposal, as it may act as the initial ‘hook’.

It needs to be written for a wider audience, so technical vocabulary has to be limited. The abstract also needs to come quickly to the proposed research. Abstracts for grant proposals usually begin with the objective or purpose of the study, move on to methodology (procedures and design), and close with a modest but precise statement of the projects’ significance.

The significance should:

• Be about one paragraph – if it needs any longer it is advisable to rethink your research or break it down into more manageable chunks.
• Explain to the reader why the study is “significant”, in the sense of advancing general knowledge.
• Explain what the benefits to the patient / health community are.
• Encourage funding.

Although you present this first in the document, write it last so that its content accurately reflects the whole proposal.

6. Introduction:

The introduction is also written so that a more general audience can easily obtain a general idea of what the project is about, and the major concepts involved. It will also typically begin with the purpose of the proposed research.  The introduction will typically be quite short, leaving the detail to the background and methodology sections.

7. Background:

It is only in the background and methodology sections that writers tend to assume that their intended audience is a specialist in their research area, and so use more technical language.

This section will include the literature review.

The purpose of a literature review is as follows:

• To become familiar with the research area and keep up to date with the current research in your area of interest.
• Identify an appropriate research question.
• Establish a theoretical framework for the research.
• Justify the need for the research.

Through the actual process of writing the literature review you, the researcher, can explore the relevant literature, formulate a problem, defend the value of the research, and compare the findings and ideas with your own. The literature review establishes a context and orientates the reader to your research topic.

The common structure of the literature review is likened to a “funnel effect”, which goes from general to more specific studies etc directly relating your intended project, ending with your research question, problem or objective.

In summary the stages of a literature review are as follows:

• General statement(s) about the field of research – the setting.
• More specific statements about the previous research.
• Statements that indicate the need for more investigation.
• Very specific statement(s) of the research question, problem or objective.

Your Trust librarians will be able to help with appropriate literature searching techniques if required.

8. Methodology:

The method or methodology section describes the steps you will follow in conducting your research. It is a very important section as assessors will scrutinise it to evaluate the feasibility and likelihood of successful completion of your proposed research.

Examine methodology sections of research articles in your research area. Arrange to discuss your research with a statistical and/or methodological specialist (Trust and other local research clinics / groups). Discuss with other researchers in your discipline the methodologies they have adopted. Consult methodology texts and statistical packages.

Overview of research:

Population/sample to be studied, including:

• How you have arrived at the sample size.
• How they will be recruited.
• Location of the research.
• Restrictions/limiting conditions.
• Sampling technique.
• Procedures.
• Analysis tools and methods.

9. Timescale:

10. Budget:

11. Ethical considerations:

• Benefits vs risks of the involvement in the project.
• Receipt of informed consent.
• Protection of participants (including data protection and storage issues).
• Privacy, minimising discomfort etc.
• Community values.

12. Dissemination strategy:

• The targets of your research eg. staff, patients, service users or carers,
• services locally and/or nationally,
• policies that drive the above services.

13. Bibliography and references:

Good luck with your project!

Useful reading: Bowling A (2002),  Research Methods in Health: Investigating Health and Health Services  2Rev Ed edition, Open University Press Polgar S and Thomas SA. (4 th   Edition 2004)   Introduction to Research in the Health Sciences.  Churchill Livingstone. MRC Good Research Practice Guidance

Realist Review: Health visiting in light Of the COVID-19 Pandemic Experience (RReHOPE)

01/06/2022 – 30/11/2023

Funded by National Institute for Health Research .

This research is about learning lessons from the delivery of health visiting services during the COVID -19 pandemic in the UK. Health visiting services are a core part of child health programmes for children aged 0 to 5. They help to ensure every child has the best start in life. Health visiting is unique because it includes home visits and reaches all new babies and their families. Health visitors work in partnership with parents and other health and social care workers to:

• help protect babies and young children from harm, • support and promote good health and development, and • identify concerns early and to ensure families get the support they need.

Health visiting services are organised and delivered differently across the UK, but the ultimate goal is the same: to improve outcomes for children. The COVID-19 pandemic that hit the UK in early 2020 placed a huge burden on health visiting services. Initially, the support they were able to provide families was substantially scaled back. At the same time, many young children and families faced increasing pressures due to indirect impacts of the pandemic. In many places, health visitors and families adapted, and services were provided just as well in new creative and different ways. It is vital that we find ways to build on the best of what has happened. We will learn lessons about the positive and negative impacts of the COVID-19 pandemic on health visiting services so we can recommend improvements to how they can be organised and delivered in the future. This in turn will help health visitors and others to deliver the best possible support to babies, young children and their families.

How do we plan to do it? Lots of studies have described some of the changes and areas of impact – some ‘good’, some ‘bad’ - during the pandemic. They have looked at the effects on children and families, service providers, and service delivery in different places. However, there is a real need to pull this learning together to find out what affect COVID-19 has had for who, in what circumstances, how and why. We plan to carry out a review of the evidence on the impact on health visiting services. We will use an approach called realist review. This involves looking at many different kinds of evidence to learn more about how services, service providers and service users have been affected by the pandemic. It is a type of evidence review that can deal with and make sense of all the differences we expect to find in the studies we include. It also involves speaking to stakeholders (health visitors, service managers, policy makers, charities, professional bodies, and parents) and involving their views in interpreting the findings.

What will the result be? We will use the findings of our review to provide recommendations to organisations who plan and deliver health visiting services, so they can organise and deliver the services better, for example more efficiently, effectively and fairly. We will work closely with the Institute of Health Visiting and other stakeholders to ensure our findings make sense and we develop suitable and accessible materials for all involved. Our review will be valuable because it will look across the whole of the UK so that people in England, Wales, Scotland and Northern Ireland can learn from each other’s experiences about what improvements might be possible.

Dr Erica Gadsby

Senior Lecturer, Health Sciences

Dr Emma King

Research Fellow, NMAHP

Outputs (1)

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

King E, Gadsby E, Bell M, Duddy C, Kendall S & Wong G (2023) Health visiting in the UK in light of the COVID-19 pandemic experience (RReHOPE): a realist review protocol. BMJ Open , 13 (3), Art. No.: e068544. https://doi.org/10.1136/bmjopen-2022-068544

• Publisher DOI
• Community Care and Health Service Policy
• Child health
• Family Health Nursing

Research centres/groups

• Institute for Social Marketing

Research themes

• Cultures, Communities & Society
• Living Well

Health visitors' experiences of using a tool in assessing infant attachment

Affiliation.

• 1 South West Essex Primary Care Trust.
• PMID: 19044130

Research and government policy emphasises the importance of the first year of life for future development, and health visitors (HVs) have been identified as key professionals to support families in order to improve attachments. This qualitative study investigated the experience of health visitors in utilising an attachment assessment tool. Semi-structured interviews were conducted with a purposive sample of six experienced HVs. There is a need to develop HV knowledge and skills in assessing attachment and supporting families where there are attachment difficulties. The tool emphasised the importance of attachment and had impacted on record-keeping, but it requires modification. The majority of HVs did not share the tool with parents due to fears about its impact on parent's emotions and behaviour, and on HVs' relationships with them. HVs reported difficulties in undertaking attachment assessments as there is insufficient time to build a relationship with parents or undertake observations. The emotional impact on HVs of working with attachment difficulties highlights their need for support and supervision. The role of the HV in assessing attachment and intervention needs clarification and warrants national investigation.

• Attitude of Health Personnel*
• Clinical Competence
• Community Health Nursing / organization & administration*
• Health Knowledge, Attitudes, Practice
• Health Services Needs and Demand
• Infant Behavior / psychology
• Mother-Child Relations*
• Nurse's Role / psychology
• Nursing Assessment / organization & administration*
• Nursing Methodology Research
• Nursing Staff / education
• Nursing Staff / organization & administration
• Nursing Staff / psychology*
• Object Attachment*
• Psychology, Child
• Qualitative Research
• Self Efficacy
• Social Support
• State Medicine
• Surveys and Questionnaires

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Each year the Graduate Program hosts some 30 to 35 Visiting Scholars and Visiting Researchers (“Visitors”) from around the world. A Visiting Scholar is generally a Professor of Law at another institution; a Visiting Researcher is generally someone who is working towards a graduate degree or doing postgraduate work at another institution. In recent years our Visitors have included a Justice of the Supreme Court of Norway, a professor in a cyberlaw research institute at the University of Tokyo, the Director of the Graduate Programme in Law at Osgoode Hall Law School, and graduate students from all over the world.

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For further information about the application process, please see  application information  for the Visiting Scholar/Visiting Researcher program.

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Selection Of 12 Dissertation Topics About Health Visiting

We don’t all go on to get our doctorates, by the ones that do are able to manage a lot of difficult academic tasks. One such task is the dissertation and it has been known to be a challenge to the best students. This is how it was meant to be, research is a serious venture and it must be done to the highest of standards. For the fresh student, this can take some getting used to.

When writing a dissertation, your choice of topic is just as important as your ability to work with it. Be very careful not to select a topic that will only ruin you and believe me a bad topic choice can. A topic must be both interesting and fun to work with, as well as within your practical capabilities. Consider this list of 12 dissertation topics about health visiting.

• What are the effects of having a male nurse attend to the delivery of a baby? Can this difference in gender affect the woman's ability to effectively deliver the child?
• What are the most troubling issues faced by health visitors practicing in developing countries?
• Do persons have the ability to properly check the authenticity of the qualification presented by a health visitor?
• In a world with increasing gender manipulation in both sexes, is it possible that this will soon affect health practice qualification requirements for professionals working on call?
• What are the advantages of having a home delivery supervised by a qualified, practicing nurse?
• In a disaster situation, should it be the choice of the victim to decide whether or not they wish to receive medical attention from a professional due to personal reasons?
• How is the safety of a visiting doctor assured when working in unfamiliar areas ?
• Is sanitation and comfort taken into enough consideration when a doctor is performing an operation outside of hospital facilities?
• The effects of the trauma young children may be faced, with when a visit turns out to be a worse case scenario.
• Can a doctor be irreparably traumatized if placed in a situation where they could have saved a person;s life, if the meeting was taking place at a proper hospital with all the facilities, instead of at an outside location?
• Should a contagious disease be discovered during a house call, does a health professional have the ability to contain the situation without risking their life?
• In what situation is a house call actually necessary?

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Original research

Variation in health visiting contacts for children in england: cross-sectional analysis of the 2–2½ year review using administrative data (community services dataset, csds), caroline fraser.

1 Population, Policy and Practice, UCL Great Ormond Street Institute of Child Health, London, UK, London, UK

Katie Harron

Jane barlow.

2 Department of Social Policy and Intervention, University of Oxford, Oxford, UK

Samantha Bennett

3 Public Health Division, Operations Directorate, Kent Community Health NHS Foundation Trust, Ashford, UK

Geoffrey Woods

4 Early Help Data & Information Team, East Sussex County Council, Lewes, UK

Jenny Shand

5 UCL Partners, London, UK

6 Care City, London, UK

Sally Kendall

7 University of Kent, Canterbury, UK

Jenny Woodman

8 Thomas Coram Research Unit, UCL Social Research Institute, London, UK

Associated Data

bmjopen-2021-053884supp001.pdf

Data may be obtained from a third party and are not publicly available. The authors do not have permission for onward sharing of the individual-level data underlying this article. Requests to access the CSDS data can be made to NHS Digital.

The 2–2½ year universal health visiting review in England is a key time point for assessing child development and promoting school readiness. We aimed to ascertain which children were least likely to receive their 2–2½ year review and whether there were additional non-mandated contacts for children who missed this review.

Design, setting, participants

Cross-sectional analysis of the 2–2½ year review and additional health visiting contacts for 181 130 children aged 2 in England 2018/2019, stratified by ethnicity, deprivation, safeguarding vulnerability indicator and Looked After Child status.

We used data from 33 local authorities submitting highly complete data on health visiting contacts to the Community Services Dataset. We calculated the percentage of children with a recorded 2–2½ year review and/or any additional health visiting contacts and average number of contacts, by child characteristic.

The most deprived children were slightly less likely to receive a 2–2½ year review than the least deprived children (72% vs 78%) and Looked After Children much less likely, compared with other children (44% vs 69%). When all additional contacts were included, the pattern was reversed (deprivation) or disappeared (Looked After children). A substantial proportion of all children (24%), children with a ‘safeguarding vulnerability’ (22%) and Looked After children (29%) did not have a record of either a 2–2½ year review or any other face-to-face contact in the year.

Conclusions

A substantial minority of children aged 2 with known vulnerabilities did not see the health visiting team at all in the year. Some higher need children (eg, deprived and Looked After) appeared to be seeing the health visiting team but not receiving their mandated health review. Further work is needed to establish the reasons for this, and potential solutions. There is an urgent need to improve the quality of national health visiting data.

Strengths and limitations of this study

• This is the first study to analyse the coverage and intensity of health visiting in England, also taking into account additional (non-mandated) contacts from the health visiting team.
• We addressed incompleteness in the national administrative data on health visiting in England by limiting our analyses to subsets of most complete data by (1) developing methods to identify a research-ready subset of the national data using comparisons to reference data sources and (2) limiting analyses to local areas with <10% missing data for vulnerability indicators.
• Our approach to dealing with incomplete data (including only most complete data) limits the generalisability of our results to the whole of England, with particular implications for results about vulnerable children and different ethnic groups.
• We were reliant on the information recorded in the administrative data, all of which is entered by the health visiting teams.
• Despite the limitations, this is an important contribution to the evidence-base about how health visiting is delivered in England, which is foundational to making any improvements or modifications to the service.

Introduction

In England, there has been a sustained cross-government focus on identifying services and policies for babies and young children to reduce inequalities. 1–5 These policies represent a response to the evidence that at age 5 year, certain groups of children are so far behind in terms of development that they will ‘struggle to ever catch up’. 6 Children who start school with lower than expected levels of development are more likely to be excluded from school or have social services involvement by the time they are 11. 6 By age 16, disadvantaged children are 18 months behind their peers and 40% of this development gap had already emerged by the age of 5. 6

There is one universal intervention programme for preschool children in England, which specifically aims to address inequalities and promote health and development of young children: The Healthy Child Programme (HCP 0–5, see figure 1 ), led by Health visitors. Health visitors are specialist child and family public health nurses who lead a team of mixed skill staff (see figure 1 ). There are models of health visiting in some countries of the world: Child Health Nurses (Sweden), Public Health Nurses (America Canada, Ireland), Child and Family Health Nurses (Australia), Plunket Nurses (New Zealand), Social Nurses (Belgium), Lady Health Visitors and Lady Health Workers (Pakistan) and Patronage Nurses (Serbia, Kosovo, Kazakhstan). However, health Visiting in England is unique in its universal coverage ( figure 1 ). A key part of the HCP 0–5 is five mandated contacts by the health visiting team before a child turns 3 year old ( figure 1 ). The last of these reviews is at 2–2½ year, and represents a vital opportunity to assess a child’s readiness to learn, their physical and social and emotional development and to identify any additional support needed to start school on a level footing with their peers. 6 7 Since 2018, there has been particularly high cross-government policy focus on the role that the 2–2½ year review can play in reducing social inequalities in cognitive development. 8–10 As part of a holistic assessment of the child during the 2–2½ year review, practitioners are required to use the Ages and Stages Questionnaire (ASQ-3 11 ), and since 2020, the Early Language Identification Measure (ELIM) is recommended. See figure 1 for a more detailed explanation of these tools.

Delivery of the HCP by health visiting teams and use of ASQ-3 and ELIM in the 2–2½ year review. 15 29–44

There is now extensive recognition that the critical 1001 days (conception to age 2) represents the best opportunity for intervening with the aim of reducing inequalities, and the Leadsom report (March 2021) highlights the need for every local authority (LA) to develop a Start for Life offer, in order to achieve this. 10 To evaluate the impact of specific policies and interventions delivered in the critical 1001 days, we need a measure of child development for all children at the end of this period (age 2) which is complete, accurate and available for analysis, such as the ASQ-3 and/or ELIM.

Despite recognition of the importance of the 2–2½ year review both for supporting individual families and for collecting data to support planning and policies at a local and national population level, there is evidence that a substantial proportion of children still do not receive a 2–2½ year review. Data from Public Health England (PHE) ‘interim reporting metrics’ (referred to as ‘metrics’ in this paper) indicate that 22% of eligible children in England did not have a record of 2–2½ year review in 2018–2020, with substantial variation across the country (27%–97%). 6 12 PHE has now been replaced with Office for Health Improvement and Disparities (2021) so we refer to (ex)PHE. The Children’s Commissioner and (ex)PHE both estimate that 9 out of 10 children receiving a 2–2½ year review also had an ASQ-3 completed but other studies have found significant variability across England in the implementation and reporting of the ASQ-3. 13–15

The subuniversal reach of the 2–2½ year review has prompted questions about whether some children are systematically more likely to miss out on a review. In 2020, the Children’s Commissioner tried to ascertain if vulnerable children were differentially likely to have a 2–2½ year review than their peers but found that most LAs did not collect the necessary data, concluding: ‘There is little evidence that local areas are ensuring that their vulnerable young children are checked’. 13 Since then, (ex)PHE has published experimental statistics, 16 suggesting that the likelihood of receiving mandated reviews varies with ethnicity, and that children living in the most affluent areas of England were more likely to receive a mandated review than children living in the more deprived areas. 10 However, these emerging social patterns need further confirmation. Additionally, we do not know whether additional (non-mandated) contacts by the health visiting team are similarly patterned. It may be, for example, that the children who miss out on a mandated review are seeing members of the health visiting team regularly for other reasons. More recent experimental statistics from (ex)PHE (June 2021) suggested that children in the most deprived neighbourhoods are more likely to get additional contacts from the health visiting, but these analyses did not also include the mandated reviews. 17 18

We aimed to ascertain whether certain groups of children were less likely to receive their 2–2½ year review than other children. We used a national administrative dataset (the Community Services Dataset; CSDS) 19 to calculate the percentage of children in 2018/2019 who received their 2–2½ year review, stratified by ethnic group, deprivation quintile, safeguarding vulnerability and Looked After Child Status. We investigated whether those that missed out on their 2–2½ year review were seeing the health visiting team for other reasons in the same time period.

Study design and setting

This study comprises a cross-sectional analysis of coverage of the 2–2½ year health visiting review and coverage and intensity of additional health visiting contacts for children aged 2 in England in 2018/2019, stratified by ethnic group, deprivation and ‘vulnerability’ indicators.

Data source

The CSDS contains individual-level longitudinal administrative data from community services in England since 2015, including data on mandated and additional contacts with health visiting services. It is operated by National Health Service (NHS) Digital, and providers of publicly funded community services (including NHS trusts, private providers and the voluntary sector) are legally mandated to submit data. CSDS captures basic child characteristics (age, ethnicity), contacts with health visiting services (type, frequency, length, date) and a wider range of identified needs in children such as referral from or to specialist services. Quintiles of deprivation are derived from the Index of Multiple Deprivation (IMD), based on the child’s postcode of usual address.

CSDS is the only child-level national source of information about health visiting in England but is a relatively new dataset, with outputs classified by NHS Digital as experimental. To our knowledge, the only published analysis of CSDS has been (ex)PHE’s experimental statistics describing patterns in mandated reviews, cited by the Leadsom review 10 16 and (separately) patterns of additional contacts. 17

Our ‘research-ready’ subset of data

We analysed a pseudonymised extract of CSDS that was held within (ex)PHE for the purpose of delivering (ex)PHE’s core work programme and priorities, for contacts between 1 April 2018 and 31 March 2019. To account for variation in the completeness of CSDS data across England and over time, we developed and applied methods for identifying a subset of ‘research-ready’ CSDS data for analysis (full details in online supplemental material 1 ). The research-ready subset of data was restricted to LAs with a high level of data completeness. We checked the completeness of CSDS by comparing the number of eligible children and health visitor contacts recorded in CSDS with ONS data on births, health visitor contacts reported within (ex)PHE metrics and anonymised health visiting data obtained directly from three LAs.

Supplementary data

Our research-ready dataset for analyses of the 2–2½ year review in 2018/2019 included 181 130 children from 33 LAs. Children in the research-ready dataset were similarly deprived but less ethnically diverse than all children in England (see online supplemental material 1 ). We identified a further subset of 13 LAs with 18 240 children with sufficiently complete data (<10% missing) for analyses of Looked After Child Status and 7 LAs with 15 485 children with sufficiently complete data on the data item ‘Safeguarding Vulnerability’.

We estimated the percentage of eligible children who received a 2–2½ year review. Our denominator comprised all children aged 2 on 31 March 2019 minus the number of children who had the 2–2½ year review and were aged 3 on 31 March 2019 (see online supplemental material 2 ) for full details). The numerator comprised children aged 2 on 31 March 2019 who had a 2–2½ year review scheduled and coded as ‘attended’ or with missing attendance data (5% of all 2–2½ year reviews).

We calculated the percentage of children who received any face-to-face contact with a member of the heath visiting team for any reason (including the mandated 2–2½ year review and additional contacts) in 2018/2019, by location of contact (home/any other location). We calculated the median and IQR for the number of all attended contacts per child (including letters and phone calls) and face-to-face 'attended' contacts. We quantified the number of children with a recorded ASQ-3 but no 2–2½ year review recorded, as an indication of 2–2½ year reviews that took place but might not have a 2–2½ year review code attached.

We stratified results by ethnicity, deprivation (IMD quintile) and vulnerability, where a ‘vulnerable’ child was defined as one with a code indicating a safeguarding vulnerability or Looked After Child at any point during 2018/2019. Both codes are entered manually by a member of the health visiting team as part of their usual care of the child. The ‘safeguarding vulnerability’ code indicates factors such as referral from police or children’s social care, significant injury, known or suspected domestic abuse, worrying parent behaviour or concerns about parental mental health. 19 Analysis of these characteristics was only conducted for LAs with less than 10% missing data for these variables (N=13 for Looked After Children and N=7 for safeguarding vulnerability). As IMD was complete for all 33 LAs and ethnicity had a similar level of completeness (16%–23% missing) across all LAs, we included 33 LAs in analyses of these variables.

Patient and public involvement

We did not conduct any patient or public involvement for this study.

In our research-ready dataset, 74% of eligible children received their 2–2½ year review, 76% had any face-to-face contact with the health visiting team in the previous 12 months (including a 2–2½ year review and additional contacts) and 78% had any contact, including letters or phone calls ( table 1 ). If we assume that all the children with an ASQ-3 record had a 2–2½ year review, our estimate of children with a 2–2½ year review increases to 81%.

Percentage of children aged 2 with a 2–2½ year review or any contact (face-to-face or other medium) with a health visiting team

*The percentage of children aged 2 with any face-to-face contact may be lower than the percentage of children with a 2–2½ year review because we reduced the number of children in the denominator for the 2–2½ year review to account for children with the 2–2½ year review aged 3 (based on age at end of 2018/2019), and a small number of 2–2½ year reviews were not be face to face (see online supplemental material 2 for full explanation).

IMD, Index of Multiple Deprivation; LAs, local authorities.

The most deprived quintile of children were less likely to have received a 2–2½ year review (72%) than children in the least deprived quintile (78%), with a gradient across quintiles. This pattern was reversed (on a small scale) when additional contacts were taken into account (80% for the most deprived vs 78% for the least deprived quintile, table 1 ). Looked After Children were much less likely to have received a 2–2½ year review recorded compared with other children (44% compared with 69%, table 1 ). However, this difference disappeared when all face-to-face additional contacts with the health visiting team were included. The lower proportion of 2–2½ year reviews for Looked After Children was not explained by missed appointments: all 90 Looked After Children with scheduled 2–2½ year reviews were recorded as ‘attended’.

The small number of children with a safeguarding vulnerability (n=205), were slightly less likely to have received a 2–2½ year review (83%) than other children (86%) and this held true when additional contacts were taken into account. Three were no clear patterns of 2–2½ year reviews across ethnic groups ( table 1 ). However, analyses that included additional contacts showed there was a lower proportion of white children receiving contacts (73%) than children in the other ethnic categories (80%–90%, table 1 ).

The majority of all children (76%), children with safeguarding vulnerabilities recorded (78%) and Looked After children (71%), had a record of a contact with health visiting services, either for a 2–2½ year review or as an additional contact ( table 1 ). The most common face-to-face activities (n=110 780) for children aged 2, other than the 2–2½ year review, were ‘other’ (31%, n=34 180), assessments (23%, n=26 015), counselling, advice or support (17%, n=18 875) and clinical interventions (15%, n=17 145), which include individualised care plans, for example parenting advice, support with behaviour and child development. These figures include multiple activities recorded for the same child (including on the same day).

A substantial proportion of all children (24%), children with a ‘safeguarding vulnerability’ recorded (22%) and Looked After children (29%) did not have a record of either a 2–2½ year review or any other face-to-face contact ( table 2 ). Most of the children without a face-to-face contact did not have a record of letters or telephone calls from health visiting services, suggesting no contacts were attempted. On average, children that had any type of contact with health visiting services saw a member of the team once in this period, compared with three times for children with a safeguarding vulnerability code and five times for children with a Looked After Child code ( table 2 ).

Median contacts per child for children aged 2 with any recorded contact during 2018/2019

Overall, 28% of children with a face-to-face contact were seen at home, and the percentage of at home contacts was greater for Looked After children (63%), children with safeguarding vulnerabilities (78%), and children living in the most deprived areas (38%) ( table 3 ).

Percentage of children aged 2 with a record of a face-to-face contact in any location and at home by child characteristic

*Rounded to nearest 5 to reduce risk of disclosure as data are subnational.

However, if all contacts with missing data on location (12%; 8805/70 695) were in fact home visits, the proportion of all face-to-face contacts that were in a child’s home could be as high as 40%.

Main findings

The majority (>70%) of eligible children in our sample, including those defined as vulnerable, were engaged with health visiting services and received their 2–2½ year review. Children in the most deprived areas were slightly more likely to miss out on a 2–2½ year review and Looked After children were much more likely to miss out on this review. However, when all additional contacts were included, the pattern was reversed (for deprivation) or disappeared (for Looked After children). This highlights the importance of including additional contacts in analyses when investigating whether the delivery of health visiting in England is socially patterned. We also found that Looked After and the most deprived children who were in contact with the health vsiting sevice according to our data received more intensive health visiting than their peers, with more frequent face-to-face contacts. Although we found no evidence that children with a safeguarding vulnerability recorded were any more or less likely to receive a 2–2½ year review or an additional contact than their peers, we did find that when this group had at least one face-to-face contact, they received more intensive health visiting than average.

Our results suggest that there are groups of high need children (eg, deprived children and Looked After children) who are engaged with the health visiting team but do not receive their mandated 2–2½ year review. We could not ascertain how far children without a 2–2½ year review were having their needs formally assessed through other routes such as a statutory Looked After Child review, as part of a Child Protection Plan or had developmental delay or additional needs identified by the health visiting team prior to the 2–2 ½ year review, as suggested by an analysis by the Children’s Commissioner in 2020. 13 The same analysis by the Children’s Commissioner reported that some LAs had stated that the 2–2 ½ year review may not always be appropriate when reviewing children with complex heath needs or development delays. 13 Our findings raise similar questions about whether the 2–2½ year review and/or the ASQ-3 is perceived as appropriate for high need groups in the population, both by professionals and parents/carers.

Our results also suggest that there might be two distinct groups of vulnerable children with regard to the receipt of health visiting. We identified a majority group of vulnerable children who received multiple face-to-face contacts within a 12-month period, often in the child’s home. This group appears to be receiving intensive health visiting, consistent with the model of proportionate universalism that underpins health visiting in England (a universal service for all children but with greater support and service provision for children in families with identified needs). The second group comprised a substantial minority of vulnerable children who were not in contact with the health visitor team at all: 22% of children with safeguarding vulnerabilities and 29% of Looked After children did not have a record of either a 2–2½ year review or any other face-to-face additional contact in the year. As we did not find evidence of attempted contacts with these children in CSDS, there is a real possibility that these vulnerable children might not have heard from or seen a member of the health visiting team within the year.

Our results on the 2–2½ year review are largely consistent with the experimental statistics published by (ex)PHE, with the exception of ethnicity. 16 (Ex)PHE found that children from ethnic minority groups were less likely than white children to receive the mandated reviews, including the 2–2½ year review. 16 The difference is likely due to poor data completeness in CSDS and different analytical approaches to dealing with this incompleteness (see online supplemental material 3 ). Our results on additional contacts are also largely consistent with the (ex)PHE experimental statistics, which suggest that children likely to have higher needs (eg, deprived children and receiving statutory child protection services) receive more additional contacts than average. 17 Our results build on the (ex)PHE statistics by bringing together mandated and additional contacts in one analysis, which facilitates for the first time estimates of children not seeing the health visiting team for any reason in the 12-month period.

Implications

Our data indicate that the health visiting service fell short of universal reach for children aged 2 year in England in 2018/2019. Together, our results and the (ex)PHE experimental statistics suggest that 2–2½ year reviews are socially patterned. However, the scale of the difference and whether it exists for different ethnic groups remains uncertain, largely as a result of poor data completeness in CSDS ( online supplemental material 3 ). Poor data remain a significant barrier to understanding how health visiting is currently delivered, and the available national data for England can only generate results which should be treated as hypotheses, with a need for further exploration.

Although the health visiting service seems to be achieving a model of proportionate universalism for some children with known vulnerabilities (with multiple visits a year, often in the child’s home), there was also a substantial minority of vulnerable children without any recorded contact from the health visiting team. This is of significant concern, given the likely concentration of health and welfare need in these groups and makes it unlikely that the current format and delivery of the 2–2½ year review is helping to address inequalities in school readiness as intended. The secondary effects of the COVID-19 pandemic, including heightened need and reduced workforce capacity (particularly the number of qualified health visitors), are likely to exacerbate the shortfall both in universal reach and provision of extra intensive services where needed. 20

Since completion of this study, the HCP is being revised to be ‘universal in reach and personalised in response’. 21 Our study evidences the gap between this policy ambition and the current reality of health visiting. 22 Further work is needed to establish reasons for low coverage of the 2–2½ year review in Children Looked After and to generate recommendations about the most suitable way of delivering the 2–2½ year review to (1) all children and (2) Looked After Children and other groups with known complex needs or vulnerabilities. Relevant factors may include skill mix (health visitor vs other team member, see figure 1 ), continuity of care, quality of reviews and referral pathways following identification of need.

In order to produce reliable estimates, researchers require access to high quality national data from health visiting services linked to other datasets (such as primary care, hospital, social care and education) for the whole of England. 23 CSDS is not yet sufficiently complete. 24 NHS Digital and (ex)PHE have been undertaking quality improvement work to address this. The findings of this study suggest that policies and/or funding to accelerate the pace of CSDS quality improvements should be considered at a national level. Further work is needed both on how best to support local practitioners to improve data recording in their systems and on how data transfer from local systems into CSDS might be improved, given the evidence that some data on health visiting contacts in local systems do not make it into CSDS. 24

Limitations

Our data did not allow us to follow a child over time, which might mean we slightly underestimate 2–2½ year reviews as some children may have had their 2–2½ year review just before or after our study period. As administrative data, CSDS codes will not capture everything health visitors identify or deliver. Information might be coded with high accuracy on local systems but ‘lost’ in the transfer to NHS Digital, for example, with use of slightly different codes. There is some evidence of this, based on our comparison of two local areas with CSDS data. 24 Second, contacts may be miscoded. Although our analyses of ASQ-3 records provide some evidence of this, the consistency of our results with other data 24 suggests that miscoding does not explain the one in five children ‘missing’ a 2–2½ year review. We know that much abuse and neglect of children will not be coded in administrative data, even if it is suspected by professionals 25 26 which will lead to underestimating differences between vulnerable and other children. Many data items were too poorly completed to use, for example, child disability and staff type (eg, health visitor, nursery nurse). CSDS does not capture quality or meaning of the interaction between health visitors and parents. To obtain a full picture of health visiting activity in England, and the contribution of this service to child health and well-being, all types of LAs need to be investigated using a triangulation of data sources, including CSDS, locally held data, surveys and in-depth qualitative data collected from professionals and families, as a study in Scotland is attempting 27 and as we have funding to do for children living with adverse childhood experiences in England. 28

Our results cannot be confidently generalised to all children in England. The children in the ‘research-ready’ data were not nationally representative in terms of ethnicity ( online supplemental material 1 ) and the excluded LAs might be systematically different from those we included which had more complete data. Although our findings should be treated as hypotheses, this study marks an important first step in making use of existing, routinely collected data to understand the coverage and intensity of health visiting services in England.

Supplementary Material

Acknowledgments.

We would like to thank individuals in Public Health England for their comments and advice on early drafts, including Wendy Nicholson within Nursing, Maternity and Early years and Kate Thurland and Helen Smith. We thank Professor Ruth Gilbert at UCL Great Ormond Street Institute of Child Health for input into study design, methods and drafts. We are grateful to Care City, Barking and Dagenham, Havering and Redbridge CCG, London Borough of Barking and Dagenham, East Sussex County Council and East Sussex Healthcare Trust and Kent County Council and Community Health NHS Foundation Trust for access to their local data and knowledge and expertise. We thank individuals at the Institute of Health Visiting for comments on this paper and earlier drafts.

Twitter: @jlwoodman_UCL

Contributors: JW and KH conceived of the study, were responsible for design of the study and supervised all analyses which were carried out by CF. JW, KH, CF, JB, SB, GW and JS all contributed substantially to the design of the study. CF, KH, JB, SB, GW, JS, SK and JW substantially contributed to interpretation of data. JS, GW and SB provided access to locally held data and gave expert advice on data and the service context. CF and JW drafted the paper and KH, JB, SB, GW, JS and SK substantially contributed to its intellectual content, including in multiple revisions. CF, KH, JB, SB, GW, JS, SK and JW approve the final version of the paper for publication. JW and KH are jointly responsible for the overall content as guarantors.

Funding: This study was funded by the National Institute for Health Research (NIHR) Policy Research Programme, funder reference: PR-PRU-1217-21301; UCL award code: 177763. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. This project is delivered as part of (ex)PHE’s 2020/2021 Life Course Intelligence business plan for child and maternal health in order to understand CSDS data quality and its suitability for further analysis to understand trends, variation and inequalities in health visiting and outcomes for children in the early years. An honorary contract with (ex)PHE enabled the researcher to work as part of the analytical team and analyse the CSDS for this purpose.This research was supported in part by the NIHR Great Ormond Street Hospital Biomedical Research Centre and the Health Data Research UK (grant No. LOND1), which is funded by the UK Medical Research Council and eight other funders. KH is supported by funding from NIHR (17/99/19).

Disclaimer: The views expressed are those of the author(s) and not necessarily those of the NIHR, the Department of Health and Social Care or Public Health England.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

Supplemental material: This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Data availability statement

Ethics statements, patient consent for publication.

Not applicable.

Ethics approval

This study involves human participants and was approved by UCL Institute of Education Research Ethics Committee on 1. May 2020 (Ref 1333). This is a secondary analysis of non-identifiable administrative health data. It would not be feasible to obtain consent, because (1) we do not have access to names and addresses with which to contact individuals, and obtaining these contact details would require a further disclosure of personal information, and (2) we used data on 181 130 children. It would not be possible to contact this large number of families. However, CSDS does not contain any direct patient identifiers such as names, addresses, NHS numbers or full dates of birth. This means the threat to patient anonymity is very low.

RESEARCH PROPOSAL – “Enhancing Quality in Patient Care”

1. relevant background of the proposed work:.

Patient care has gained immense importance in recent years due to the increased number of medical disorders and increasing awareness amongst people and patients. Increased demand in hospitals and healthcare centres to improve the patient’s health condition has become a formidable factor for all the health care professionals at every hierarchy level. Errors have become a part of the system, due to increase in the number of challenging issues that affect the deteriorating health condition of the patient. Improving the health condition by minimising system and human errors has become a crucial concern in the health industry. Health professionals have identified several causative factors for poor quality and implemented various measures to improve the quality of the situation. Unlike the old paradigm, the person approach, where the percentage of errors recorded was high, the system approach came into existence and is these days reducing the percentage of errors and increasing the complexity of the system (Warburton. 2005). In addition to the improvement of organisation, there are many other improvements underway, which include the public involvement in primary health research (Jonathan et al., 2010). According to the current situation, the health care team is also getting educated to reduce the risk of errors (Colin. 1995). Awareness of errors also created a significant impact on the safety of the patient and hence many resources were created and modified to reduce the risk (Warburton. 2005). These days, usage of health information technologies lead to improvement of the health. In the study by Connie and David (2010), through the innovative technology, the system can be advanced globally to reduce the socioeconomic barriers in various countries. Appropriate use of technology at the right time would cause miracles in the health sector (Connie et al., 2010). Many health care changes initiated in certain categories of patients decreased the risk of errors. Some of the measures included direct, personal supervision and decreased adverse reactions in case of paediatric and geriatric patients (Cambern. 2009). Another main implementation is an introduction of rapid assessment and initial patient treatment team (RAPT) in accident and emergency patients, reducing the risk to life (Cronin et al., 2005).

Summarising all the developments, quality in health care can be achieved by the academic and technical knowledge of the physician along with the communication of the health care assistants and public. In addition, appropriate utilisation of resources and tools is also essential to achieve the improvement of patient’s health condition as a target (Michelle. 1996).

2. HYPOTHESIS: Objective of the current project is to demonstrate new techniques based on studies done in previous years and to improve the quality of patient care, which is a considerable challenge for the health sector.

The tasks to accomplish include:

• To increase safety of patients by relevant initiatives. 12/16/2010 Research Proposal
• Team working within the health care sector and involvement of patients and public in primary research.
• Implementing innovations in patient care.

3. SCOPE: The following tasks would be undertaken as a part of proposed research:

• Task 1: To investigate the past studies on existing and improved health care system.
• Task 2: To appreciate the improvements in the health sector in the recent years.
• Task 3: To design research in order to increase quality in health care system and patient safety by reducing errors and implementing innovations.

4. METHODOLOGY AND APPROACH:

1. Patient Safety Initiatives: Although lots of experiments were done in patient safety in recent decades, it still remains a challenge for health professionals. These days, hospitals are spending enormous resources to reduce errors, which are appreciated. However, implementing all the proposals is not easy (Warburton. 2005). It is cost involving and depends on manpower to a greater extent, which is difficult to control.

The safety improvements cannot be implemented and always be accurate as it changes according to the situation. Improper design and rapid enforcement of safety measures would only cause meagre improvement to patients (Warburton. 2005).

There are several approaches and studies for obtaining maximum benefit out of the available resources. They are:

• Setting up a committee of professionals across the health sector to highlight vital safety measures in the hospital according to the patient conditions (Warburton. 2005). This method is time consuming and complicated. The results obtained were vague and could not improve the quality of patient.
• Another approach, which is my area of research interest, is setting up an Economic Evaluation Loop (EEL), based on the recommendation of Leape and others (1999) which would be based on utilising available evidence to establish priorities. In this approach, priorities would be set according to the analysis of available resources and outcomes of the changes (Warburton. 2005).

Accordingly, evaluation would be based on the benefits and resources available for research. Later, detailed research would be completed according to Warburton (2005), by which alternative assumptions could be identified and compiled. Finally, an additional research network would be framed to fulfil the requirements in the best possible way to reduce critical gaps (Warburton. 2005). This loop is a variant of Technology assessment iterate loop, called TAIL (Tugwell et al., 1986; Tugwell et al., 1995).

By this EEL approach, critical gaps in the research area can be identified by discussions among the health professionals and these gaps, which are usually overlooked, would be considered to provide the best safety measures within the scope of resources.

Increasing research on safety implementation to patients often raises a question of how much safety is essential. Warburton (2005) describes that there is no upper bound for providing safety to patient as demands of improving safety measurements never drop. He explains this fact by the figure depicted in figure 2 of this paper.

The curve depicts total costs of errors to the society against the level of safeguards and clearly reveals that the safety measures are implemented based upon the cost effectiveness. When initial safety methods are employed it is initially cheap, and then with the increase of costs, negligible benefits are obtained due to less reduction of adverse effects when cost measures increases. This continues uphill, further reducing the benefits with increased cost (Warburton. 2005).

The curve depicts total costs of errors to the society against the level of safeguards and clearly reveals that the safety measures are implemented based upon the cost effectiveness. When initial safety methods are employed it is initially cheap, and then with increase of costs, negligible benefits are obtained due to a drop in the reduction of adverse effects when cost measures increases. This continues further reducing the benefits with increased cost (Warburton. 2005).

Figure 2: Cost to the society versus level of safeguards Figure adopted from Warburton (2005).

In my research project, EEL with regards to one of the patient safety will be studied in the clinical environment and conclusions would be compiled accordingly in the thesis work.

2. Patient and Public Involvement in Primary Research: Involvement of potential patients and the public is an import contribution to primary research.

According to Beresford’s argument, the research experiments tend to be more accurate when the distance between the potential patients and the investigator is minimal (Beresford. 2005).

Furthermore the public, the part owners for research as taxpayers, have an equal right to subscribe for the success of research, which would improve their lives directly (Boote et al., 2010).

Additionally, public involvement at all stages of research, especially the primary level, would reduce the initial value of resources by direct focus on potential treatment areas and thus contribute to the quality of care (Boote et al., 2002; Thompson et al., 2009).

One of the approaches by which quality of patient care would be enhanced is performing clinical trials in a particular diseased population. In these clinical trials, design of the study would be based on their relevant experiences. Questionnaires would be prepared accordingly to consider general experiences and needs in that category of patients. These questionnaires are then compiled together to establish a basic structure of description and would form the research theme. Initially consent forms would be taken from the patients, and research would be carried out by contacting them regularly for feedback. All the issues the public need to be addressed would be collected for better supervision and analysis would be carried on to ensure results favouring the potential patients. This attempt ensures that questions of the potential patients would be answered and treatment becomes patient friendly, reducing the stress on the investigator, and the patient.

In this project, clinical trial is closely observed on a class of patients. Later analysis would be done on how the involvement of public and potential patients influences quality of patient care.

3. Team Working Team working is essential for effective health care management, especially in critical conditions like chronic health disorders. To achieve quality team working amongst all the health care professionals, interaction among them in day-to-day service is necessary. To ensure team-working skills in hospitals and health care centres, educating the team would be required.

Education should be a dynamic process that is patient-centred (Coles et al., 1995). Education amongst the health professionals should be multidisciplinary rather than self-centred research.

Patients and their cares should get an education alongside to improve care and hygiene. Thus, quality in health care would be achieved by a patient-centred approach.

In addition, regular team meetings and interaction between the physicians, care takers and patients would improve the quality of patient care. Discussion among patients and physicians during the treatment would be useful to record the treatment procedure, which could be useful in future investigation of the same kind.

In this project, team-working skills within a selected hospital would be improved and quality of patient care would be compared.

4. Innovations in Delivering Patient Care Many advances have been introduced in the health sector in the recent years. Use of modern technology is one that simplified the administration of health sector. Health information technologies (HIT) include mobile phones, computers, self-administration equipment, health decision-making management devices, life style modification devices, monitoring chronic illness and patient education devices (Gustafson et al., 2002). Socioeconomic barriers cause slow penetration of HIT in developing countries (Connie et al., 2010).

Setting up an appropriate HIT within a health sector is a challenge for technologists as many factors would be taken into account while considering it, and to facilitate the system, a framework would be employed. By the use of this framework, approaches could be studied and the best HIT would be employed (Connie et al., 2010). Some factors that would be taken into consideration include situational factors like setting and clinical domain, technological factors and work force (Connie et al., 2010).

Other remarkable innovations include the establishment of RAPT, which is a rapid assessment and initial patient treatment team within accident and emergency, where the patient would be allocated 4 hr of comprehensive treatment in an emergency condition (Cronin et al., 2005).

Personal care within the department of paediatrics and geriatrics is one of the other innovations (Cambern et al., 2009). This would reduce the incidence of risk and errors causing adverse reactions in them.

My intention of study would be to try and implement some of the innovations in a hospital environment and examine the quality in terms of health care. 12/16/2010 Research Proposal.

5. FACILITIES TO BE USED: Many facilities would be used to perform the following objectives in accordance with available resources and these include:

• Discussion with various people across the health sector to set up the economic evaluation loop in order to set up priorities in patient safety.
• Seeking clearance to participate in some clinical trials which would enable to understand the association of public and patients in primary health research.
• Visiting hospitals and health care organisations to examine and record the facilities for a certain group of patients.
• Getting initial training in the system of control within the primary health sector to minimise the occurrence of errors.
• Many paper and poster articles analysing different approaches of patient education.
• Certain use of technology to study the improvement of quality with the use of innovation.

6. PROGRAM SCHEDULE AND DELIVERABLES: (A basic gnat chart without dates, client should set up dates appropriately)

7. FUNDS AVAILABLE: Client has to decide according to available funding

8. REFERENCES: Warburton, R.N. (2005) Patient safety-how much is enough? Health policy,71, pp.223-232.

Perrow, C. (1984) Normal accidents: living with high risk technologies. New York Basic Books.

Leape, L. L., Forward, I.N (1999). Error reduction in health care: a systems approach to improving patient safety. Jossey-Bass.

Tugwell, P.,Bennett, K.,Feeny, D.,Guyatt, G.,Haynes, R.B. (1986) A frame work for the evaluation of technology. Institute in research and public policy, pp.41-56.

Tugwell, P.,Sitthi-Amorn, C.,O’Connor, A.,Hatcher-Roberts ,J.,Bergevin, Y.,Wolfson, M (1995)

Technology assessment. Old, new and needs-based. International Journal of Technology Assesment in Health care, 11(4), 650-662.

Jonathan, B.,Wendy, B.,Claire.,B. (2010) Public involvement at the design stage of primary health research: A narrative review of case examples. Health policy, 95, pp.10-23.

Boote, J.,Telford, R., Cooper, C. (2002) Consumer involvement in health research: a review and research agenda. Health policy, 61(2), pp.213-236.

Beresford, P. (2005) Developing the theoretical basis for service user/survivor-led research and equal involvement in research. Epidemiologia e psichiatria Sociale, 14(1), pp.4-9.

Thompson, J.,Barber, R.,Ward, P.R.,Boote, J.D.,Cooper, C.L.,Armitage, C.J. (2009) Health Researchers’ attitudes towards public involvement in health research. Health expectations, 12(2), pp.209-220.

Coles, C. (1995) Educating the health care team. Patient Education and Counseling, 26, pp.239-244.

Connie, V.C.,David, R.K. (2010) A technology selection frame work for supporting delivery of patient-oriented health interventions in developing countries. Journal of Biomedical Informatics, 43, pp.300-306.

Cambern, K. (1952) A quality improvement program. Pediatrics and child health, pp.5172-5175.

Cronin, J.G.,Wright, J.RN. (2005) Rapid assessment and initial patient treatment team-a way forward for emergency care. Accident and Emergency Nursing, 13, pp.87-92.

Gustafson, D.H.,Hawkins, R.P.,Boberg, E.W.,Mc Tavish, F.,Owens, B.,Wise, M. (2003) 10 years of research and development in consumer health informatics for broad populations, including the underserved. Med inform, 65(3), pp.169-177.

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Daniel Boone National Forest may begin charging fees to use Red River Gorge trails, increase camping prices

SLADE, Ky. (WKYT) - The Red River Gorge is one of Kentucky’s most popular nature areas, and if you want to pay a visit - you might have to start paying soon.

New fees are being proposed for 22 different sites in the Daniel Boone National Forest, with 19 of them in the gorge. The other three sites are in the forest’s London District.

It’s an area that people will drive from hours away in any direction to see, with a hike in the Red River Gorge often evoking adjectives of amazement.

“Oh, it was just beautiful and wild - gorgeous,” Ralph Mancik said, without a pun intended.

It’s the reason Eric Dodd with the U.S. Forest Service says they’re seeing a dramatic increase in visitation.

“On average, we probably see about half a million visitors each year,” said Dodd. He serves as a program manager for the Cumberland District of the forest, in which the gorge lies. “We need to keep up with visitor demand and visitor experience.”

As the gorge gets busier, they’re looking into how they can better manage the area.

“We’re kind of at this point where we have to designate (backcountry) campsites, adopt some of the user-created trails and re-design them,” Dodd said.

Dodd notes there are currently around 1,000 backcountry camping areas, and they are looking to bring that number down to 350 defined sites. He says that will help support the area’s eco-system, as they have too many people camping in unauthorized areas with delicate habitats, like rockshelters.

But Dodd says to do this work, they need more funding.

So, they’re proposing new fees at popular trails and recreation areas like Gray’s Arch Trailhead, Chimney Top, and Sky Bridge, as well as raising prices for backcountry camping.

Day use areas like trailheads are currently free, but would cost $5 a day, $7 for three days, for $50 annually under the proposed changes. Backcountry camping fees would increase from $5 a day to $10, with additional price changes for front-country and group sites.

Dodd says the funds will support the Forest Service as they maintain these sites and bring improvements to aging facilities.

But what do the Gorge’s visitors think about the change?

“I feel like most parks that I visit to go hiking, you tend to pay a fee,” said Tracy Paszotta, who was visiting from Illinois. “If it’s as small as you say, five dollars doesn’t seem unreasonable to me.”

“I’m not real positive on that, because I think something that’s beautiful should be free,” said Mancik, who grew up in Lexington. “That was one of the things I enjoyed about it - we just showed up and enjoyed it.”

Opinions are seemingly split, and Dodd says the Forest Service knows it will have to strike a delicate balance.

“If it’s not done properly, it could reduce that feeling of solitude and freedom out camping,” said Dodd.

So that’s why they want to hear your voices before any decision becomes final.

“With public input, if we do it properly, it will help the resource but also preserve that recreational experience,” Dodd said.

The Forest Service will hold a public meeting on June 11 from 6-7:30 p.m. in Stanton at the Powell County Lions Club, and they’re accepting feedback on the proposal through July 31. If approved, the changes could come as soon as January 1, 2025.

Copyright 2024 WKYT. All rights reserved.

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Hamas Says It 'Positively' Views Gaza Ceasefire Proposal Set Out by Biden

Hamas Says It 'Positively' Views Gaza Ceasefire Proposal Set Out by Biden

FILE PHOTO: Smoke rises following an explosion in Gaza, amid the ongoing conflict between Israel and the Palestinian Islamist group Hamas, near the Israel-Gaza border, as seen from Israel, May 30, 2024. REUTERS/Amir Cohen/File Photo

GAZA (Reuters) -Palestinian Islamist group Hamas on Friday said it had a positive view of the contents of a three-phase ceasefire proposal announced by U.S. President Joe Biden for a permanent ceasefire in Gaza.

"Hamas confirms its readiness to deal positively and in a constructive manner with any proposal that is based on the permanent ceasefire and the full withdrawal [of Israeli forces] from the Gaza Strip, the reconstruction [of Gaza], and the return of the displaced to their places, along with the fulfilment of a genuine prisoner swap deal if the occupation clearly announces commitment to such deal," the group said in a statement.

Hamas' position signals a change in attitude from the group, which in recent months had accused the U.S. of siding with Israel and obstructing attempts for a ceasefire.

"Hamas sees Biden's position now more focused on pressuring Israel to return to negotiations with a different attitude, or they (Israel) could risk clashing with the Americans," a Palestinian official close to the mediation efforts told Reuters.

War in Israel and Gaza

Rifts between Biden and Netanyahu over red lines in Gaza has set up a potential showdown between the two leaders, raising questions about whether the U.S. might restrict military aid if Israel continues its offensive in the now-devastated enclave.

Prime Minister Benjamin Netanyahu's office said that Israel had authorized negotiators to present a Gaza truce deal after Biden revealed details of the ceasefire plan.

Palestinian health authorities estimate more than 36,280 people have been killed in Gaza since Israel attacked the enclave in response to an Oct. 7 Hamas assault in southern Israel. The Hamas attack killed around 1,200 people, according to Israeli tallies.

(Reporting by Nidal Al Mughrabi and Ahmed Tolba; Writing by Adam Makary; editing by Deepa Babington)

Copyright 2024 Thomson Reuters .

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