Re: RE: client perceptions of HV

April 5, 2002

Charlene, that would be great

Many thanks

Margaret

RE: client perceptions of HV

> Margaret,

> Jacky Moseley, from Norwich did a MSc on client views on HV. She did not

> publish it but I think it highlighted things like the importance of the

> personal relationship with clients which helped build their confidence to

> access/participate other services etc. Is this the stuff you are looking

> at? I'm sure I haven't done it justice in the description but I can put

you

> in touch if you wish.

> Charlene

>

April 5, 2002

Margaret, Palo Almond did a literature review for a research proposal that we

were preparing, about clients' views of health visiting. There were masses of

positives especially about 'traditional home visiting' approaches; fewer

negatives, largely about clinics, lack of continuity and adverse, judgemental

attitudes. Biggest complaint was 'not enough' health visiting when needed.

Biggest critique comes from sociologists, who view this demand as evidence of

HVs making themselves indispensible. Almost no client views about new

approaches; neither negative nor positive; they are just not asked! Not

enough information about ethnic groups, lower economic groups, young parents

etc. either.

Interesting that managers want to control HVs: or is that a way of

controlling clients? Best wishes

Margaret Buttigieg wrote:

> Charlene, that would be great

>

> Many thanks

>

> Margaret

> RE: client perceptions of HV

>

> > Margaret,

> > Jacky Moseley, from Norwich did a MSc on client views on HV. She did not

> > publish it but I think it highlighted things like the importance of the

> > personal relationship with clients which helped build their confidence to

> > access/participate other services etc. Is this the stuff you are looking

> > at? I'm sure I haven't done it justice in the description but I can put

> you

> > in touch if you wish.

> > Charlene

> >

April 5, 2002

Hi

I used the word " controlling " as that is how the practitioners see it - they

talk about " they " meaning those they see in the hierachy above them. I

frequently get that. When you ask who " they " are, it becomes more difficult

to actually say but for me it is about the disempowement and the felt

control.

I am not sure on the part of managers controling clients- rather I think it

is the misunderstanding about health vistors do and the fact that it is

difficult to measure outcomes in the short term. We come back again to the

fact that HVs and to extent school nurses do not fit in with the medical

model or the governments tick box approach.

Margaret

RE: client perceptions of HV

> >

> > > Margaret,

> > > Jacky Moseley, from Norwich did a MSc on client views on HV. She did

not

> > > publish it but I think it highlighted things like the importance of

the

> > > personal relationship with clients which helped build their confidence

to

> > > access/participate other services etc. Is this the stuff you are

looking

> > > at? I'm sure I haven't done it justice in the description but I can

put

> > you

> > > in touch if you wish.

> > > Charlene

> > >

April 6, 2002

have you a reading list ?

Also hope you enjoy the workshop -apologies.Ann.

>From: Cowley <sarah@...>

>Reply-

>

>Subject: Re: RE: client perceptions of HV

>Date: Fri, 05 Apr 2002 22:35:40 +0100

>

>Margaret, Palo Almond did a literature review for a research proposal that

>we

>were preparing, about clients' views of health visiting. There were masses

>of

>positives especially about 'traditional home visiting' approaches; fewer

>negatives, largely about clinics, lack of continuity and adverse,

>judgemental

>attitudes. Biggest complaint was 'not enough' health visiting when needed.

>Biggest critique comes from sociologists, who view this demand as evidence

>of

>HVs making themselves indispensible. Almost no client views about new

>approaches; neither negative nor positive; they are just not asked! Not

>enough information about ethnic groups, lower economic groups, young

>parents

>etc. either.

>

>Interesting that managers want to control HVs: or is that a way of

>controlling clients? Best wishes

>

>Margaret Buttigieg wrote:

>

> > Charlene, that would be great

> >

> > Many thanks

> >

> > Margaret

> > RE: client perceptions of HV

> >

> > > Margaret,

> > > Jacky Moseley, from Norwich did a MSc on client views on HV. She did

>not

> > > publish it but I think it highlighted things like the importance of

>the

> > > personal relationship with clients which helped build their confidence

>to

> > > access/participate other services etc. Is this the stuff you are

>looking

> > > at? I'm sure I haven't done it justice in the description but I can

>put

> > you

> > > in touch if you wish.

> > > Charlene

> > >

April 8, 2002

People mostly become managers to sit on top of people not

be underneath them or lead from behind.Ie they are fulfilling their

driven psychological..often unmet..needs. we should see everything

as much as possible in psychological terms and what is more, unless they

are helped to change their attitudes, they stay the same wherever they pop

up..the same as we do.

Our job now is not to continually masturbate over policy documents

but regain contact with users and be driven by their needs (not wants/

expectations..it should be about working in a way that frees up the oft

overused time of professionals to deliver their core skills mixes, as much

through building community capacity as through dumping routine work for

which there

is very little proven effeicay or that could be down by folks trained to

deliver

those specific interventions...just as for cataract surgery in India or

Russia).

All service users are voters and knowing what they need and what the

gaps/overlaps

etc are in services can inform our justifciations for the resources and

changes required..

in that we way we are advocates for THEM not ourselves or our wretched

professional

representatives or organisation. We are there for them..not the other way

round

and partnerships and power-sharing to improve collaboration is a great

outcome,

since it removes all the system-political learned helplessness and moves

people to

indepenedence and recovery. Meet a mum who has been through it? Simply

connect.

Manning

www.primhe.org

Re: RE: client perceptions of HV

Margaret, Palo Almond did a literature review for a research proposal that

we

were preparing, about clients' views of health visiting. There were masses

of

positives especially about 'traditional home visiting' approaches; fewer

negatives, largely about clinics, lack of continuity and adverse,

judgemental

attitudes. Biggest complaint was 'not enough' health visiting when needed.

Biggest critique comes from sociologists, who view this demand as evidence

of

HVs making themselves indispensible. Almost no client views about new

approaches; neither negative nor positive; they are just not asked! Not

enough information about ethnic groups, lower economic groups, young parents

etc. either.

Interesting that managers want to control HVs: or is that a way of

controlling clients? Best wishes

Margaret Buttigieg wrote:

> Charlene, that would be great

>

> Many thanks

>

> Margaret

> RE: client perceptions of HV

>

> > Margaret,

> > Jacky Moseley, from Norwich did a MSc on client views on HV. She did

not

> > publish it but I think it highlighted things like the importance of the

> > personal relationship with clients which helped build their confidence

to

> > access/participate other services etc. Is this the stuff you are

looking

> > at? I'm sure I haven't done it justice in the description but I can put

> you

> > in touch if you wish.

> > Charlene

> >

April 8, 2002

Margaret/Chris/Ann/,

I am aware that I keep repeating myself, but I believe strongly that one of the

main strengths of health visiting is the fact that we work at the cross-roads of

the public health/medico/psycho/social services.We work in an independent style

that enables us to acknowledge complexities in a client's life and wait

patiently for that individual to arrive at a point were they are ready for

action. We are then in a knowing position to signpost and support as they make

what maybe a significant change for them but a microscopic change in a public

health perspective. That is the strength and subtlety of family public health as

delivered by health visitors. Oh, and yes, such patience, knowledge-base and

skill requires a top-class employee who deserves a good wage and working

conditions in a capitalist society.

Ruth

Margaret Buttigieg wrote:

> Thanks you made me feel better.

>

> I have been feeling really old and tired the last few weeks but I feel

> better today and have had a good sorting day today so reading your response

> now was an added tonic.

>

> I wanted to say to you Ann in response to your question to " by

> intuition and instinct " as I often feel I do my working with people by feel

> and observation of their reactions but then I guess would probably say

> that it is experience and development of understanding of people and all

> those things.

>

> I like your response to Ann in more depth and agree with it entirely.

> I could apply it to many of the places I am working and find it incredible

> that those in the leading positions cannot see it what they need to do and

> the changes they need to make. But still if they did not have problems - I

> would not get work so I suppose that is one consolilation.

>

> It seems to me that SENATE members could sort the world if they let us!!

>

> Margaret

>

> RE: client perceptions of HV

> > > > >

> > > > > > Margaret,

> > > > > > Jacky Moseley, from Norwich did a MSc on client views on HV. She

> > >did

> > > > not

> > > > > > publish it but I think it highlighted things like the importance

> of

> > >the

> > > > > > personal relationship with clients which helped build their

> > >confidence

> > > > to

> > > > > > access/participate other services etc. Is this the stuff you are

> > > > looking

> > > > > > at? I'm sure I haven't done it justice in the description but I

> can

> > >put

> > > > > you

> > > > > > in touch if you wish.

> > > > > > Charlene

> > > > > >

April 8, 2002

Dear ,

I would be interested to know what size caseload and need level of these clients

would lead to a situation where a health visitor acts as you describe. We have

+/- 400 children per wte HV plus child protection work, community work and in my

case my Executive Committee work too. I also do teenage HP clinics and

counselling. Am I a freak or do I have such a small caseload in comparison to

others?

I do wonder what point health visiting if you do not have time to listen. If all

an HV can do is child protection and developmental surveillance work then

perhaps skill mix with greater numbers of staff task orientated would be better.

Ruth

Bidmead wrote:

> Dear Ruth,

>

> You write 'We work in an independent style

> that enables us to acknowledge complexities in a client's life and wait

> patiently for that individual to arrive at a point were they are ready for

> action'.

>

> I only wish that this were true for all health visitors. The time allowed

> to 'wait patiently' is sadly lacking in many places where there is

> understaffing and an agenda that is driven by the needs of the service

> rather that the needs of the client. In many places the one 'new birth

> contact' is all that happens as far as a home visit is concerned and in that

> visit the health visitor can feel constrained to give information about,

> services, immunisation, development assessments, cot death, feeding, and

> carry out a family health assessment sadly using a required questionnaire to

> be completed. All this in itself can take at least an hour and then it is

> time to move on to the next client. What chance is there for the client to

> lead the agenda? Where is the time to wait patiently? Working in this way

> would be ideal but I wonder how many health visitors in practice actually

> have the time allowed and sufficient staffing levels to be able to do this?

>

> Perhaps I'm being a bit pessimistic here. However, I cannot help

> remembering a health visitor I was training in listening skills recently who

> told me that if she really listened to clients then she might actually

> discover something was wrong e.g. postnatal depression. Having discovered

> this then she would be committed to more home visiting and she simply didn't

> have the time. I was shocked that health visitors might not listen to

> clients in order to avoid detecting health needs but as the same time more

> than ever convinced that if one wants to discover health needs one only has

> to listen to the client and be open to their agenda. This health visitor

> obviously knew this and was actively avoiding doing it. Reform is obviously

> needed in the way in which we work to allow us to spend time with people.

> It is what clients want as I believe there is research that shows that

> clients do value home visiting but consistently complain that there is not

> enough of it.

>

> RE: client perceptions of HV

> > > > > > >

> > > > > > > > Margaret,

> > > > > > > > Jacky Moseley, from Norwich did a MSc on client views on HV.

> She

> > > > >did

> > > > > > not

> > > > > > > > publish it but I think it highlighted things like the

> importance

> > > of

> > > > >the

> > > > > > > > personal relationship with clients which helped build their

> > > > >confidence

> > > > > > to

> > > > > > > > access/participate other services etc. Is this the stuff you

> are

> > > > > > looking

> > > > > > > > at? I'm sure I haven't done it justice in the description but

> I

> > > can

> > > > >put

> > > > > > > you

> > > > > > > > in touch if you wish.

> > > > > > > > Charlene

> > > > > > > >

April 8, 2002

I agree entirely , but I am sure that there are upper limits to the numbers

of

individuals (regardless of level of need) that one HV can relate to. Perhaps

the

poor staff in those areas lists have reached that limit. Would there

be

any value in profiling those individuals case loads - at least then service

providers would know the upper limits/situations that should trigger emergency

situations?

Ruth

Cowley wrote:

> Sorry, I buried my response to Ruth's question at the end of a long message

> (called opening the debate: because I think 'universal vs. selective' is such

> an important issue), to which Woody has just responded. The points I was

> making about the arithmetic of the spread of services applies here: numbers

of

> children/population do not equate to numbers of needs.

>

> best wishes

>

> Bidmead wrote:

>

> > I am talking about an inner London situation where the staffing levels are

> > down 30%-50% in the localities and staff are carrying caseloads of 400-500

> > families (not children) with high child protection and not enough social

> > workers to cover children on the CP register. This was a year ago and I am

> > aware that things are changing with the advent of the PCT. They certainly

> > needed to.

> >

> > RE: client perceptions of HV

> > > > > > > > > >

> > > > > > > > > > > Margaret,

> > > > > > > > > > > Jacky Moseley, from Norwich did a MSc on client views on

> > HV.

> > > > She

> > > > > > > >did

> > > > > > > > > not

> > > > > > > > > > > publish it but I think it highlighted things like the

> > > > importance

> > > > > > of

> > > > > > > >the

> > > > > > > > > > > personal relationship with clients which helped build

> > their

> > > > > > > >confidence

> > > > > > > > > to

> > > > > > > > > > > access/participate other services etc. Is this the stuff

> > you

> > > > are

> > > > > > > > > looking

> > > > > > > > > > > at? I'm sure I haven't done it justice in the description

> > but

> > > > I

> > > > > > can

> > > > > > > >put

> > > > > > > > > > you

> > > > > > > > > > > in touch if you wish.

> > > > > > > > > > > Charlene

> > > > > > > > > > >

April 9, 2002

In my experience caseload profiling is dynamic. The evidence-based indices of

deprivation/need highlight some of the families with potential need however,

knowledge of the individual capabilites of the family members as well as their

emotional health creates an in-depth knowledge. Thus caseload analysis is

moulded by knowledge gleaned of relationship dynamics, as well as psychological

and fiscal health. The level of service input is similarly calibrated.

For example at the moment I am working intensively with a client abused in

childhood by her mother who is suffering enormous distress because her ability

to parent her 15mth old child is impaired, in turn this is rebounding within her

relationship with her husband and his family. (I am using Solihull approach).

This family would not have registered as a family in need had I profiled my

caseload two months ago - although I have been seeing them routinely since an

antenatal visit and waiting patiently for the mother to open up and talk of her

suffering for a long time - her EPND Score was only 3 at 6/52 and 5 at 8/12.

Does that help your thinking?

Ruth

ann ebeid wrote:

> can you explain how you would profile a caseload Ruth?Also Please try and

> send your dissertation again.Thanks, Ann.

>

> >From: ruthngrant <ruthngrant@...>

> >Reply-

> >

> >Subject: Re: RE: client perceptions of HV

> >Date: Mon, 08 Apr 2002 22:31:50 +0100

> >

> >I agree entirely , but I am sure that there are upper limits to the

> >numbers of

> >individuals (regardless of level of need) that one HV can relate to.

> >Perhaps the

> >poor staff in those areas lists have reached that limit. Would

> >there be

> >any value in profiling those individuals case loads - at least then service

> >providers would know the upper limits/situations that should trigger

> >emergency

> >situations?

> >

> >Ruth

> >

> > Cowley wrote:

> >

> > > Sorry, I buried my response to Ruth's question at the end of a long

> >message

> > > (called opening the debate: because I think 'universal vs. selective'

> >is such

> > > an important issue), to which Woody has just responded. The points I

> >was

> > > making about the arithmetic of the spread of services applies here:

> >numbers of

> > > children/population do not equate to numbers of needs.

> > >

> > > best wishes

> > >

> > > Bidmead wrote:

> > >

> > > > I am talking about an inner London situation where the staffing levels

> >are

> > > > down 30%-50% in the localities and staff are carrying caseloads of

> >400-500

> > > > families (not children) with high child protection and not enough

> >social

> > > > workers to cover children on the CP register. This was a year ago and

> >I am

> > > > aware that things are changing with the advent of the PCT. They

> >certainly

> > > > needed to.

> > > >

> > > > RE: client perceptions of HV

> > > > > > > > > > > >

> > > > > > > > > > > > > Margaret,

> > > > > > > > > > > > > Jacky Moseley, from Norwich did a MSc on client

> >views on

> > > > HV.

> > > > > > She

> > > > > > > > > >did

> > > > > > > > > > > not

> > > > > > > > > > > > > publish it but I think it highlighted things like

> >the

> > > > > > importance

> > > > > > > > of

> > > > > > > > > >the

> > > > > > > > > > > > > personal relationship with clients which helped

> >build

> > > > their

> > > > > > > > > >confidence

> > > > > > > > > > > to

> > > > > > > > > > > > > access/participate other services etc. Is this the

> >stuff

> > > > you

> > > > > > are

> > > > > > > > > > > looking

> > > > > > > > > > > > > at? I'm sure I haven't done it justice in the

> >description

> > > > but

> > > > > > I

> > > > > > > > can

> > > > > > > > > >put

> > > > > > > > > > > > you

> > > > > > > > > > > > > in touch if you wish.

> > > > > > > > > > > > > Charlene

> > > > > > > > > > > > >

April 9, 2002

,

I am in the delicious position where the boundaries you mention are coterminous

and in an

area where the group of health visitors are dynamic and have always

persisted(covertly for

some of the time!) in public health initiatives - particularly knowledge of

local

facilities and networking with other agencies. We are, therefore, well placed

now to move

ahead with most of the baseline work already undertaken.

However, as the funding is linked to evidence, and acceptable evidence in public

health

terms (RCTs) is not always available we are in a bit of a Catch 22 with our

community

initiatives.

Ruth

Cowley wrote:

> That is a good point Ruth and clients persistently tell us (even though our

paymasters

> do not always want to believe them) that personal relationships matter

enormously. I

> am not sure that health visiting is only about relating to individuals though.

Even

> though that is surely an absolutely fundamental requirement, there is the

wider public

> health issue of an overview of the health needs in an area, which may not

appear in a

> traditional form of caseload. I think it is where that has gone awry, that

the

> numbers of HVs have been allowed to drift downwards so badly.

>

> There has always been a debate, too, about the meaning of the term 'caseload'.

Is it

> measured in terms of indexed children aged under five? Or does it include

their

> families? (if so, who counts as 'family'?) Or files in the filing cabinet?

Or active

> cases? Or is it closer to the idea of the GP caselist, with HVs having a

> responsibility for people that they rarely see, but who know they can turn to

the HV

> if they need her? (GPs usually, I think, have 2,000 or even 3,000 individuals

on

> their list). Is it about individuals, or something else? What about a

geographic

> area or a school or, bearing in mind Jan's fascinating description of her

work, a

> prison?

>

> I wonder if others, like me, worry about the often-expressed view that we

should be

> swapping 'caseloads' for 'public health' work? I do not want to suggest that

we should

> be ignoring that wider public health/community view, because I believe it is

the

> combination of individual plus community-wide work that is distinctive to

health

> visiting. It also happens to be what the evidence shows works best in terms

of health

> improvement. best wishes

>

> ruthngrant wrote:

>

> > I agree entirely , but I am sure that there are upper limits to the

numbers of

> > individuals (regardless of level of need) that one HV can relate to.

Perhaps the

> > poor staff in those areas lists have reached that limit. Would

there be

> > any value in profiling those individuals case loads - at least then service

> > providers would know the upper limits/situations that should trigger

emergency

> > situations?

> >

> > Ruth

> >

> > Cowley wrote:

> >

> > > Sorry, I buried my response to Ruth's question at the end of a long

message

> > > (called opening the debate: because I think 'universal vs. selective' is

such

> > > an important issue), to which Woody has just responded. The points I was

> > > making about the arithmetic of the spread of services applies here:

numbers of

> > > children/population do not equate to numbers of needs.

> > >

> > > best wishes

> > >

> > > Bidmead wrote:

> > >

> > > > I am talking about an inner London situation where the staffing levels

are

> > > > down 30%-50% in the localities and staff are carrying caseloads of

400-500

> > > > families (not children) with high child protection and not enough social

> > > > workers to cover children on the CP register. This was a year ago and I

am

> > > > aware that things are changing with the advent of the PCT. They

certainly

> > > > needed to.

> > > >

> > > > Re: RE: client perceptions of HV

> > > > > >

> > > > > > > Margaret/Chris/Ann/,

> > > > > > > I am aware that I keep repeating myself, but I believe strongly

that

> > > > one

> > > > > > of the

> > > > > > > main strengths of health visiting is the fact that we work at the

> > > > > > cross-roads of

> > > > > > > the public health/medico/psycho/social services.We work in an

> > > > independent

> > > > > > style

> > > > > > > that enables us to acknowledge complexities in a client's life and

> > > > wait

> > > > > > > patiently for that individual to arrive at a point were they are

ready

> > > > for

> > > > > > > action. We are then in a knowing position to signpost and support

as

> > > > they

> > > > > > make

> > > > > > > what maybe a significant change for them but a microscopic change

in a

> > > > > > public

> > > > > > > health perspective. That is the strength and subtlety of family

public

> > > > > > health as

> > > > > > > delivered by health visitors. Oh, and yes, such patience,

> > > > knowledge-base

> > > > > > and

> > > > > > > skill requires a top-class employee who deserves a good wage and

> > > > working

> > > > > > > conditions in a capitalist society.

> > > > > > >

> > > > > > > Ruth

> > > > > > >

>

April 9, 2002

Chris

I do entirely agree with you - however, in a cash starved organisation that is

dominated by empiricism putting together an arguement that holds water is not

difficult - it is merely dismissed because it does not conform to RCT. I have

presented several documents drawing together valid research based on qualitative

studies, meta-analyses etc - but have had it dismissed as not acceptable.

However, whilst my patients recognise quality and respond to it with strong

health gains I have stunning successes in my clinical practice and I am a happy

health visitor.

Ruth

Manning wrote:

> Dear Ruth

>

> Whose evidence is it anyway? Why is it that just about every other business

> places such high store and value on the user experience of the product. Is

> there no evidence that communication and quality of continuity of care®

> make little difference to outcomes? How are we bamboozled by seemingly

> robust justifications that actually fall over when challenged...I think it

> is very easy for people to sound so convincing..but I think we should all be

> grouping together to give these folks who have so much certainty that they

> are right, a bit more of a buffeting..how do we know what we know? how well

> do we know it? I would argue that the loss of experience and narrative is

> doing so much to destroy our connections with others. Look at what the

> evidence has done in terms, over my lifetime alone, in terms of what we

> shoul/should not be eating/drinking/doing and anyway..many of the

> interventions that are going to count in people's lives are not going to

> come from official systems or even from DH budgets.

>

> Has anyone noticed how there is a remarkable co-terminosity between what

> funders consider to be important areas of activity

> and the evidence available..and how this still so often relates, in a

> completely objective way, of course, to issues around

> minimising the costs of service delivery.

>

> We desperately need to start showing how process matters as much as

> outcome..it is incredible how we particulate life and then forget to put it

> back together. We need longitudinal qualitative research..a person's story

> or narrative is not " just anecdotal " ..these are high order brains telling us

> the measurements of how we are doing. In public health terms, if many

> employees in a factory are sick with mental ill-health or stress-related

> illness..they are telling us about the levels of psychotoxicity in their

> working environments, in the same way

> as canaries died when the coal gas levels went up..it IS evidence!! Whether

> bean counting bureacrats place a value on it or not,, does not take the

> intrinsic value away. Evidence based practice MUST include personal

> experience and intelligence gathered from whatever source.

>

> There is a game to play here, which is to gain the funding for overt work

> aligned to the funder's agendas, whilst doing the work in such a way that we

> generate the results that will justify the quality agenda that we feel is

> lacking. The evidence that we are not getting it right is burn-out and

> demoralisation. WE NEED those missing elements and the research drive must

> be to do the research which justifies the preservation of core values of

> care and communication. We also need to remember to put all the evidence

> back together again and remember that, whatever the evidence, there will

> always be bean counters interested in its suppression (witness the original

> Black report and the last Govt). We also need to remember that most of our

> daily lives are not based on evidence and many of our human and caring

> practices are not based on evidence that stands up to penetrative analysis,

> in terms of the relevance of the studies to the people we may be seeing. And

> maybe, all those who tell us how important it is may one days themselves

> practice some form of evidence-based decision-making..I am thinking here of

> party political decisions mostly. Is the evidence of a four year combative

> political system convincing in terms of the development and sustaianbility

> of the country's infrastructure eg?

>

> And is it not remarkable that so much of what is happening is uncoupled from

> any overall strategy coupled to evidence and funding must be for innovative

> projects that usually fold after two-three years..too many pilots and not

> enough fuel? Where is evidence-based politics..we have to justify every

> penny, but the deeper you go within the system, the harder it is to identify

> the monies..this too must change. If people are to hold the line on issues,

> we must know the quantities.

>

> Chris

> www.primhe.org

>

> Re: RE: client perceptions of HV

>

> ,

>

> I am in the delicious position where the boundaries you mention are

> coterminous and in an

> area where the group of health visitors are dynamic and have always

> persisted(covertly for

> some of the time!) in public health initiatives - particularly knowledge of

> local

> facilities and networking with other agencies. We are, therefore, well

> placed now to move

> ahead with most of the baseline work already undertaken.

>

> However, as the funding is linked to evidence, and acceptable evidence in

> public health

> terms (RCTs) is not always available we are in a bit of a Catch 22 with our

> community

> initiatives.

>

> Ruth

> Cowley wrote:

>

> > That is a good point Ruth and clients persistently tell us (even though

> our paymasters

> > do not always want to believe them) that personal relationships matter

> enormously. I

> > am not sure that health visiting is only about relating to individuals

> though. Even

> > though that is surely an absolutely fundamental requirement, there is the

> wider public

> > health issue of an overview of the health needs in an area, which may not

> appear in a

> > traditional form of caseload. I think it is where that has gone awry,

> that the

> > numbers of HVs have been allowed to drift downwards so badly.

> >

> > There has always been a debate, too, about the meaning of the term

> 'caseload'. Is it

> > measured in terms of indexed children aged under five? Or does it include

> their

> > families? (if so, who counts as 'family'?) Or files in the filing

> cabinet? Or active

> > cases? Or is it closer to the idea of the GP caselist, with HVs having a

> > responsibility for people that they rarely see, but who know they can

> turn to the HV

> > if they need her? (GPs usually, I think, have 2,000 or even 3,000

> individuals on

> > their list). Is it about individuals, or something else? What about a

> geographic

> > area or a school or, bearing in mind Jan's fascinating description of her

> work, a

> > prison?

> >

> > I wonder if others, like me, worry about the often-expressed view that we

> should be

> > swapping 'caseloads' for 'public health' work? I do not want to suggest

> that we should

> > be ignoring that wider public health/community view, because I believe it

> is the

> > combination of individual plus community-wide work that is distinctive to

> health

> > visiting. It also happens to be what the evidence shows works best in

> terms of health

> > improvement. best wishes

> >

> > ruthngrant wrote:

> >

> > > I agree entirely , but I am sure that there are upper limits to the

> numbers of

> > > individuals (regardless of level of need) that one HV can relate to.

> Perhaps the

> > > poor staff in those areas lists have reached that limit.

> Would there be

> > > any value in profiling those individuals case loads - at least then

> service

> > > providers would know the upper limits/situations that should trigger

> emergency

> > > situations?

> > >

> > > Ruth

> > >

> > > Cowley wrote:

> > >

> > > > Sorry, I buried my response to Ruth's question at the end of a long

> message

> > > > (called opening the debate: because I think 'universal vs. selective'

> is such

> > > > an important issue), to which Woody has just responded. The points I

> was

> > > > making about the arithmetic of the spread of services applies here:

> numbers of

> > > > children/population do not equate to numbers of needs.

> > > >

> > > > best wishes

> > > >

> > > > Bidmead wrote:

> > > >

> > > > > I am talking about an inner London situation where the staffing

> levels are

> > > > > down 30%-50% in the localities and staff are carrying caseloads of

> 400-500

> > > > > families (not children) with high child protection and not enough

> social

> > > > > workers to cover children on the CP register. This was a year ago

> and I am

> > > > > aware that things are changing with the advent of the PCT. They

> certainly

> > > > > needed to.

> > > > >

> > > > > Re: RE: client perceptions of HV

> > > > > > >

> > > > > > > > Margaret/Chris/Ann/,

> > > > > > > > I am aware that I keep repeating myself, but I believe

> strongly that

> > > > > one

> > > > > > > of the

> > > > > > > > main strengths of health visiting is the fact that we work at

> the

> > > > > > > cross-roads of

> > > > > > > > the public health/medico/psycho/social services.We work in an

> > > > > independent

> > > > > > > style

> > > > > > > > that enables us to acknowledge complexities in a client's life

> and

> > > > > wait

> > > > > > > > patiently for that individual to arrive at a point were they

> are ready

> > > > > for

> > > > > > > > action. We are then in a knowing position to signpost and

> support as

> > > > > they

> > > > > > > make

> > > > > > > > what maybe a significant change for them but a microscopic

> change in a

> > > > > > > public

> > > > > > > > health perspective. That is the strength and subtlety of

> family public

> > > > > > > health as

> > > > > > > > delivered by health visitors. Oh, and yes, such patience,

> > > > > knowledge-base

> > > > > > > and

> > > > > > > > skill requires a top-class employee who deserves a good wage

> and

> > > > > working

> > > > > > > > conditions in a capitalist society.

> > > > > > > >

> > > > > > > > Ruth

> > > > > > > >

> >

April 9, 2002

Thanks - a colleague of mine is writing a module of her Masters in Public

Health on client perceptions of HV service and I will offer your abstract.

Ruth

W Coles wrote:

> Dear Ruth, Margaret and all list

> have put below a summary from my thesis as it is relevant to your

> discussion. I used the effectiveness of interpersonal skills as a

> marker for process to outcome evaluation. Clients provided the causal

> link to demonstrate the effectiveness of interventions. They provided

> examples of learning to demonstrate this effectiveness. Hope its

> useful

>

> THE VALUE OF HEALTH VISITORS' INTERPERSONAL SKILLS IN PROMOTING

> HEALTH: A SEARCH FOR EVIDENCE OF EFFECTIVENESS

> UWCM, CARDIFF, PhD 2000

>

> DR LISA COLES RGN RHV BA PHD

>

> THESIS SUMMARY

> Health visiting interventions and their effect on outcomes are

> difficult to evaluate. The promotion of health is fundamental to

> health visiting and interpersonal skills are crucial to its success.

>

> Interpersonal skills are said to be goal directed and amenable to

> differentiation. Measuring the outcomes of health care and evaluating

> health promotion both require a precision of taxonomy of

> interventions. But the reality of the lived situation when working

> with families challenges these constructs.

>

> The participants for this qualitative process-to-outcome study were

> all the health visitors employed in a South Wales Valley community

> health service unit and some of their clients. Health visitors'

> interpersonal skills and health promoting objectives were identified

> from the content analysis of narratives of critical events, using

> Flanagan's critical incident technique. For the clients' perception

> of these skills and associated health gain, the text of tape recorded

> in-depth semistructured interviews was analysed with the aid of the

> NUD.IST qualitative data analysis software.

>

> A taxonomy of the health visitors' interpersonal skills was built and

> confirmed from the clients' perception. Causal links between the use

> of skills and the outcomes of health attitude, knowledge and

> behaviour changes were identified by clients. The health promotion

> was client centred and relevant to social and psychological need,

> incorporating adult emotional and relationship needs as much as baby

> and child nutrition, behaviour and illness needs. It was evaluated as

> successful by clients not through overt goal orientation but through

> an informal concept of purposive befriending.

>

> The way to measure the effectiveness of health visitors'

> interpersonally skilled interventions is to seek from clients

> evidence of learning outcomes and of satisfaction with the service.

> Visibility of this qualitative data for evaluation purposes can be

> increased by incorporating a relevant classification into current

> nursing language databases about diagnosis, interventions and

> outcomes. In addition, formal assessment of outcomes would benefit

> from a framework that acknowledges interventions as relevant to the

> context of needs. This takes the measurement of outcome away from a

> medical model and into a socially constructed model.

>

> Contact e-mail ColesEW@...

> Telephone Work 029 2071 5479/6933

> To leave a message anytime: 01446 760776

>

> On 20 Apr 2002 at 14:52, Manning wrote: