RE: [pafsinterestgroup] FNP and HV roles

January 13, 2008

Thank you for this response you are right - in many ways we need to avoid going for the bait and be a bit bigger that the camp that clearly would like nothing better than just to close the door on health visiting. Having said that, it does all provoke irritation and great emotion. It was an odd day in Manchester. I did find myself being careful about what I said to who on the day. Most attendees were managers, some commissioners, but very few practitioners. I was the only person from education as I think it was aimed at service.

The MP Anne Keen, made some remarks about HVs and tupperware boxes which the audience found highly amusing, but unfortunately for me set a tone of ridicule at HVs suggesting they were always the ones - even in her days as a district nurse - who were out of touch with reality and little too middle class for the population being served (although she clearly just travelled up to Manchester from London first class on the train as she'd commented on receiving her bacon buttie!).

Unfortunately rather than celebrating the comparisons between the HV role and the Olds' nurse - it was almost used as a way of saying this is all new and HV stuff is old hat and out of touch. I think it will become the thorn in our side and ultimately the thing that stabs us in the heart as services are increasingly directed at specific needs groups - in this case the 19yrs and under first time mothers,- leaving the majority of families in ordinary situations facing parenthood for the first or second time to battle it alone and seek out resources for themselves via the web or a local group. There are lots of subtleties about the FNP that allow non HVs to assume that its all about extra investment with a loss to rest of the population. For example reference is constantly made to it fitting into the progressive universalism model, but of course it is only universal for the <20yr olds, first time parents. Without a generic service, working beyond what the CHPP might look like, others who aren't first time parents or who are not even very old when having a first or second baby at 20+ will not get the opportunity to develop a close relationship with a professional service. Is it that these roles are going have to depend on the voluntary/third sector organisation activities. In which case the chances of equity across the social divides and across the country are going to be even more difficult to achieve. At the end of the day all babies have a risk of being born to parents who for what ever reason have found attaching to them difficult. We know that PND affects all mothers rich or poor, older or younger. Likewise we know all parents can face high anxiety, high stress and great difficulty in acting warmly to their babies when they seemingly have a 'difficult temperament' and don't sleep or settle easily. And we now know more than ever that for parents to be able to act warmly, be attuned to the baby's needs matters to the infants neurological development. Stress and aggression in households is not limited to the very youngest parents - it runs throughout society and is therefore affecting the brain development and social tendencies of many infants and children. All parents their should have the opportunity to get to know and feel confidence in a professional who they feel that they can at a later stage of parenthood contact for guidance and support.

Interestingly one of the quotes from a mother put up by the FN practitioner presenting said "all mothers should access to these nurses". I remarked on this to someone from the FNP central office over the lunch break and the immediate response was that it was absolutely unnecessary and that the evidence (of course the Olds US evidence) shows that it is only the youngest who benefit from such intensive home visiting. The problem is that this is being translated as meaning that therefore all other home visiting has no evidence and therefore not a cost efficient way to deliver a service. I did try to point out to this person that it is not just the very young who face challenges in raising children and that they too needed to have some close, sensitive contact with professionals able to deliver solution/strengths focused approaches to them as individuals and in their own homes. This though I feel still feel on deaf ears. The response was: "well we will have to wait and see what the commissioned review of reviews shows".

Did anyone else go to one of these sessions?

From: pafsinterestgroup [mailto:pafsinterestgroup ] On Behalf Of CowleySent: 13 January 2008 11:20pafsinterestgroup Subject: Re: [pafsinterestgroup] FNP and HV roles

Dear

I felt very sad when I read this, but not surprised. I am so sorry to have been so slow to respond, but felt it needed some explanation and consideration. I will be really interested to know if anyone thinks my analysis is inaccurate or if it resonates with their observations, too.

When the idea of the Olds programme was first mooted for the UK in 2006, it was clear that it needed to be implemented by health visitors or midwives; nurses were only mentioned because they don't have health visitors or midwives in the US, and because of the title of the programme. That did cause some ruffled feathers in the DH, because they had spent a lot of time and energy trying to abolish health visiting by removing them from statute and closing their register; now here was the Social Exclusion Task Force promoting health visiting as if it still existed and as if its practitioners could do a good job. So, in the first instance, there was a lot of discussion about how important it was to ensure this programme could, once it was rolled out, be integrated into the overall health visiting service. I recall meeting Kate Billingham just after her first visit to the US, which was the cause of much merriment because she said the nurses implementing the programme in the States were exactly like health visitors; spoke, dressed (pearls and cardigans!) and even sat like health visitors. Olds has been at pains to point out the the nurses in the US 'are not just nurses, not like ordinary nurses,' and he is reportedly extremely impressed with the calibre of the health visitors implementing the programme here. I understand there are around 2-3 midwives and 1 children's nurse (does anyone have exact figures?), but the vast, vast majority of practitioners implementing the pilots are health visitors.

Pause for two thoughts. First, any study or experience of implementing new services and new roles shows that it always generates enormous enthusiasm and excitement, because of

- the contrast to the absolute drudgery of everyday practice; protection from much of the stress

- the joy of having sufficient time and funding,

- the stimulation of new education and training, demonstrating and expanding participants' consciousness

- the interest shown by managers and others (Hawthorne effect?)

- those chosen to participate are usually selected as a result of fierce competition, so they start out excellent and enthusiastic.

The FNP is no exception; it would be an absolute disaster if, having had so much money, support and time spent on them, the practitioners were not saying how exciting and different it all is, so that is what they are saying. Also, given the antipathy by the DH nurses towards health visiting, practitioners would be firmly disapproved of, if they ever mentioned that they used their health visiting skills. It has to be made clear to everyone that these are NURSING pilots, not health visiting ones (someone emailed me about these recently, and said she had initially typed 'FNP plots,' which seems more to the point really)!

Second, over the last year, various other things have happened in health visiting. The health visiting review singled out the FNP as one of the two roles being promoted as appropriate for health visitors. It also, without actually saying so, indicated that 'health visiting services' as such would be disbanded. Although a universal and expanded CHPP would continue to be available, delivered by a team 'led by a health visitor,' the review indicated that would be all that needed commissioning, apart from the FNP. Although that shows a stunning lack of knowledge of health needs and what health visitors actually deliver on the ground, it is a view that has been promoted fairly consistently by the DH nurses for some time now, and it is always delivered through this 'professional titles don't matter' mantra. 'Professional titles don't matter' is a code for 'don't mention health visiting, only talk about nursing.' There has also been a view that we should 'get away from caseloads' for health visitors. In other words, only deliver the CHPP and referrals to the FNP, either as part of general practice or in the children's centre; then we won't have to pay for expensive professionals holding undifferentiated caseloads and high levels of responsibility.

Also, the post-registration consultation for 'modernising nursing careers' has proposed five career routes, of which 'child family and public health' is one. There is (of course) no mention of health visiting, except to point out that the health visiting review was part of this initiative and that the third part of the NMC register is a bit of a nuisance which spoils their neat model (well, it isn't phrased so undiplomatically, I admit!) This dialogue has run alongside a serous dip in both student health visitor numbers and health visitors in post. This drop in capacity is being used to promote these ideas as positive and manageable, whilst visions of a universal service linked in with one that also meets needs identified (even if not so severe as to merit the FNP) through universal contacts, are promoted as old-fashioned, unnecessary, without an evidence base and unhelpful to health inequalities. Again, that shows considerable ignorance, but professional rivalry, and the need to promote nursing at all costs, is clearly more important in some quarters than the need to serve the community, reduce health inequalities or meet the health needs of the youngest and most vulnerable members of our population.

Back to the roll-out of the second round of FNP pilots. The fact that this second tranche of money has been made available is a testimony to their success; that is down to the health visitors implementing the programme, and to those supporting them in their new role. It is not down to nursing. However, if the DH acknowledges that it is health visitors who have done this, they might have to start saying positive things about health visiting. And if anything is positive, they want nursing to own it. What is so depressing about this, is that it is such a clear example of professional rivalry being the source of damage to service provision. We really should be developing services to meet needs (all needs, across the social gradient, not just a tiny minority) not to meet a professional agenda, however exciting this new role might seem.

There are two cheerful things, though. First, there do seem quite a few places now talking about reinvesting in health visiting services, after 2007 being such a disastrous year of cuts and cutbacks. Second, the new health visiting programmes, developed as a result of changes to the standards in 2002 and 2004, are far better than the old SPQ (community nursing) programmes developed in the late 1990s, and they appear far more consistent across the country. So, for once, it seems that the PCTs might be leading the way more positively. I hope Maggie will say, if her CPHVA antennae are picking up different things to me, but perhaps we should focus on pushing on those open doors, rather than fighting the old-school nursing hegemony, which is just so destructive.

Thank you for bringing this news to the group, , and like you, I will be pleased to hear of anyone else's experiences and views.

kind regards

On 10 Jan 2008, at 10:41, Whittaker wrote:

I wonder did anyone else go to one of the two presentations this week about the Family Nurse Practitioner pilot. I was at the Manchester one yesterday and whilst I came away feeling enthused about this exciting role, I simultaneously felt quite sad about what was muted about health visiting.

I asked about training in the future for these new roles and whether if as nurses it would be expected that they would sit on the third part of the register. The response was for a preference not to be.

I suggested might it be an opportunity for developing, say a 3-4 year, direct entry programme for this nurse and the response was well that's a interesting idea and yes possibly.

When another question was asked about what will happen to the families when the child is two and the FNP service ceases - will the family go under the wing of the generic HV service? The answer was well we don't even know whether we will have a HV service of that nature by the time these children are 2yrs (in about 18mths time).

The FNP programme of course is dedicated to the title nurse - one of the key presented opened with saying this is not about titles, but I noted that reference throughout the day by the central team was to nurses' skills and what nurses can offer and little if any reference to skills brought from existing health visiting base.

I'd be interested to hear any other experiences from these days. Are any of you in this group working as FNP?

WhittakerSenior Lecturer Dept of NursingRoom 432 Brook BuildingUniversity of Central LancashirePreston PR1 2HE

Tel: 01772 893786Kwhittaker1uclan (DOT) ac.uk http://www.uclan.ac.uk/facs/health/nursing/research/groups/children/index.htm

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January 13, 2008

Hi

Your comments are very interesting and very valid - my findings around the country is that the Family Nurse developments have had little impact except where they are happening and of course at present that is few places. And indeed Wales - where I am working - has not gone down that route and seems to be recognising the need for Hvs and SN and the improtance of an integrated agenda.

I also find that once you get talking with social care, children centre staff and education - they want and value health visitors and school nurses and want their health input.

Like you to I am picking up that a number of PCTs are reinvesting in health visiting - came acrosos two in London last week who are both seeking staff at band 6 and 7. I understand one of them has had something like 20 child deaths in the last year - do not know the reasons why - but they have decided that to prevent some of this they needs more health visitors.

Interesting stuff but you are so right about the professional arguments. In the late 70s and 8os when I was involved in health visitor education they were quite strong then but they were not so vicious as I find them today - it is very sad and all I can see it that it is detrimental to childen and families and wonder whether they have ever read the policy and considered that the tile "Every Child Matters" is important and means you need people on the ground to address that agenda

Look forward to further debate on these issues and will report to SENATE if I pick up any more information on the ground

Margaret

RE: [pafsinterestgroup] FNP and HV roles

Thank you for this response you are right - in many ways we need to avoid going for the bait and be a bit bigger that the camp that clearly would like nothing better than just to close the door on health visiting. Having said that, it does all provoke irritation and great emotion. It was an odd day in Manchester. I did find myself being careful about what I said to who on the day. Most attendees were managers, some commissioners, but very few practitioners. I was the only person from education as I think it was aimed at service.

The MP Anne Keen, made some remarks about HVs and tupperware boxes which the audience found highly amusing, but unfortunately for me set a tone of ridicule at HVs suggesting they were always the ones - even in her days as a district nurse - who were out of touch with reality and little too middle class for the population being served (although she clearly just travelled up to Manchester from London first class on the train as she'd commented on receiving her bacon buttie!).

Unfortunately rather than celebrating the comparisons between the HV role and the Olds' nurse - it was almost used as a way of saying this is all new and HV stuff is old hat and out of touch. I think it will become the thorn in our side and ultimately the thing that stabs us in the heart as services are increasingly directed at specific needs groups - in this case the 19yrs and under first time mothers,- leaving the majority of families in ordinary situations facing parenthood for the first or second time to battle it alone and seek out resources for themselves via the web or a local group. There are lots of subtleties about the FNP that allow non HVs to assume that its all about extra investment with a loss to rest of the population. For example reference is constantly made to it fitting into the progressive universalism model, but of course it is only universal for the <20yr olds, first time parents. Without a generic service, working beyond what the CHPP might look like, others who aren't first time parents or who are not even very old when having a first or second baby at 20+ will not get the opportunity to develop a close relationship with a professional service. Is it that these roles are going have to depend on the voluntary/third sector organisation activities. In which case the chances of equity across the social divides and across the country are going to be even more difficult to achieve. At the end of the day all babies have a risk of being born to parents who for what ever reason have found attaching to them difficult. We know that PND affects all mothers rich or poor, older or younger. Likewise we know all parents can face high anxiety, high stress and great difficulty in acting warmly to their babies when they seemingly have a 'difficult temperament' and don't sleep or settle easily. And we now know more than ever that for parents to be able to act warmly, be attuned to the baby's needs matters to the infants neurological development. Stress and aggression in households is not limited to the very youngest parents - it runs throughout society and is therefore affecting the brain development and social tendencies of many infants and children. All parents their should have the opportunity to get to know and feel confidence in a professional who they feel that they can at a later stage of parenthood contact for guidance and support.

Interestingly one of the quotes from a mother put up by the FN practitioner presenting said "all mothers should access to these nurses". I remarked on this to someone from the FNP central office over the lunch break and the immediate response was that it was absolutely unnecessary and that the evidence (of course the Olds US evidence) shows that it is only the youngest who benefit from such intensive home visiting. The problem is that this is being translated as meaning that therefore all other home visiting has no evidence and therefore not a cost efficient way to deliver a service. I did try to point out to this person that it is not just the very young who face challenges in raising children and that they too needed to have some close, sensitive contact with professionals able to deliver solution/strengths focused approaches to them as individuals and in their own homes. This though I feel still feel on deaf ears. The response was: "well we will have to wait and see what the commissioned review of reviews shows".

Did anyone else go to one of these sessions?

From: pafsinterestgroup [mailto:pafsinterestgroup ] On Behalf Of CowleySent: 13 January 2008 11:20pafsinterestgroup Subject: Re: [pafsinterestgroup] FNP and HV roles

Dear I felt very sad when I read this, but not surprised. I am so sorry to have been so slow to respond, but felt it needed some explanation and consideration. I will be really interested to know if anyone thinks my analysis is inaccurate or if it resonates with their observations, too.