Agenda item

For the Sub-Committee to receive an update on the Health Visiting Service, and to reflect on a recent meeting between Members and frontline Health Visitors.

The Sub-Committee considered a report set out on pages 15 to 32 of the agenda, which provided an update on the Health Visiting service in Croydon. Chris Terrahe (Deputy Director of Nursing at Croydon Health Services (CHS)) introduced the item and went through the presentation provided in the agenda to the Sub-Committee.

Matthew Kershaw (Chief Executive of CHS and Place Based Lead for Health) explained that the context for Health Visiting was tough nationally, but that it was the job of the service to respond to this challenge. The Sub-Committee heard that the systems and processes of the service were being reviewed, as well as the way that staff were being looked after and the ways in which leadership was working or needed improvement and support. Work was being undertaken with the commissioning team and Public Health, looking at the roles of senior staff, and a new operational manager was now in place; it was hoped that this would provide significant help in the short term. It was acknowledged that whilst some areas of the service were performing better, there were some areas where improvement had not happened. The Director of Public Health highlighted that changes were beginning to happen in the Health Visiting service, and that senior leadership were committed to making improvements. Andrea Cuff (Associate Director of Operations CHS) explained that the workforce would be vital to the improvement journey, and that recruitment and retention were a large element of this as well as the health and wellbeing of staff. Members heard that staff input into the improvement journey was important, and Team Leaders were feeding into all of the workstreams of the improvement plan.

The Chair explained that Members of the Sub-Committee had met with Health Visitors on the 13^th June to speak with them about their experiences of working in the service, and that these discussions had helped to inform the lines of questioning for this item. Members noted that the move to ‘One Front Door’ had been highlighted in the report as an improvement to the service, but had been raised by staff as something that was making aspects of their jobs more difficult. The Chief Executive of CHS and Place Based Lead for Health explained that the service was in the middle of a change programme and that there were advantages and disadvantages to individual elements of this; the change programme needed to be evaluated in its totality, but it was acknowledged that this was difficult as it was still in progress. The Associate Director of Operations CHS added that ‘One Front Door’ had provided improvements for service users, but agreed that there needed to be a balance between the benefits that improvements provided for service users, the best use of limited resources, and the quality of life for staff.

It was highlighted that when Health Visiting reports were written up post-visit, staff were under the impression that this could be done anywhere except their own homes. The Deputy Director of Nursing at CHS noted that this was not correct, and that processes to look at the possibility of flexible working for Health Visitors was something that was being investigated; it was highlighted that any flexible working would need to be balanced with the health, wellbeing and supervision of staff. The Chief Executive of CHS and Place Based Lead for Health agreed, and highlighted the importance of face-to-face interactions in the delivery of Health Visiting.

Members commented on the positive experience of those who were able to access the service, but noted that staffing levels had got worse since the last update to the Sub-Committee in November 2022; it was asked what was being done to improve this. The Chief Executive of CHS and Place Based Lead for Health responded that this was not the position the service wanted to be in, but explained that the Director of Public Health had been supporting work in developing a new Operational Manager post and changing the way that the Health Visiting team was being led. The national shortage of Health Visitors and the needed improvements in Croydon were acknowledged, and Members heard that the experience of the individual staff member was something that needed to be improved; it was hoped that ultimately this would lead to better recruitment and retention in the service. The Chief Executive of CHS and Place Based Lead for Health stated that they were committed to do everything possible to increase staffing levels.

The Sub-Committee asked what the national vacancy rate was for Health Visitors, and the Deputy Director of Nursing at CHS explained that this was difficult to ascertain, but that the service was looking at if the Croydon offer to staff was competitive with comparable neighbours. Members heard that a recruitment campaign would be launched soon, whilst new ways of working were investigated to move the model of care delivery forward; Croydon had commissioned additional training for staff through Kingston University, as it was felt that the national commissioning of specialist training did not meet Croydon’s needs. The Chief Executive of CHS and Place Based Lead for Health committed to working to improve Croydon’s position at a pace greater than the national rate, as Croydon had further to travel. It was acknowledged that additional work to think about how this would be measured needed to be undertaken. The Director of Public Health explained that this could be discussed with the Institute of Health Visiting, who were already supporting service improvements, and the development of the offer for staff. Members noted that the national vacancy rates for Health Visitors mirrored those of Croydon.

The Sub-Committee asked what the risk to families was as a result of the vacancies in the service. The Chief Executive of CHS and Place Based Lead for Health explained that the production of risk assessments and the prioritisation of service users was a necessity, and that there was always an effort to direct resource where it was most needed; the operational changes being made to the service always accounted for trying to reduce the risk to families. The Associate Director of Operations CHS explained that those most in need were seen first wherever possible, and that this approach and triage was supported by the ‘One Front Door’. The Deputy Director of Nursing at CHS explained that New Birth Visits were being prioritised, as this gave the service the earliest opportunity to assess any risk, alongside the 6-8 week checks that could identify emergent risks. Members heard that there were non-mandated checks, such as baby weight and feeding clinics, to ensure that there was support where it was needed and to provide multiple opportunities for families to interface with services, but it was acknowledged that risk was growing for some individuals and families for a variety of reasons. Members asked if there was any knock on affect from the vacancies to a greater need of Children’s Services, and praised the planned establishment of the complex needs Health Visiting team. The Corporate Director for Children, Young People & Education explained that all services were focussed on the mitigation of risk, but that consequences were always felt where a safeguarding partner was under resourced; Members heard that partners were used to communicating about this and mitigating it where possible, but that not all risk could be nullified. The Sub-Committee asked how many Child Protection Conferences Heath Visitors had attended, and heard that Health Visitors had attended 810 conferences in 2022/23.

The Sub-Committee asked whether the current housing crisis was a factor in staff retention and recruitment, and whether any mitigations for this were in place. The Chief Executive of CHS and Place Based Lead for Health explained that some offers of accommodation were provided for new starters from overseas nursing recruitment, and acknowledged that the housing crisis was a factor, alongside the cost of living, that could affect recruitment and retention. Members heard that all that could be done would be, but that resources were not unlimited. Members asked about travel times between visits, and what was being to done to minimise this and increase efficiency in the service. The Deputy Director of Nursing at CHS responded that homeworking was one element of this, but that the roadways naturally provided obstacles that were beyond the control of the service; the introduction of the ULEZ was highlighted as something that could potentially make this more difficult. It was explained that the Health Visiting service was based in six localities to try to reduce geographical distances between the visits of each staff member.

Members asked how the priorities for 2023/24 had been decided, and if specific budget had been assigned to any of them. The Deputy Director of Nursing at CHS explained that these were developed from the aims of the service, feedback, conversations with the commissioning team and the national agenda for Health Visiting. Members heard that the service was fully funded and that all initiatives were carefully costed in collaboration with the commissioning team. These priorities would be monitored through a number of Key Performance Indicators (KPIs), for example vacancy rates, which were built into the improvement strategy and could be shared with Members. The Chief Executive of CHS and Place Based Lead for Health added that additional metrics were being considered, for example to monitor if Croydon was improving at a greater rate than the national picture. The Director of Quality, Commissioning & Performance added that monthly meetings took place between the commissioning team, Health Visiting senior leadership and Public Health colleagues; a more senior summative contract-monitoring meeting took place quarterly, and it was suggested that additional metrics would be discussed at the next one of these and fed back to the Sub-Committee. The Director of Quality, Commissioning & Performance explained that reporting to these meetings had improved and this had led to better reinvestment of budget into the improvement priorities of the service.

Members asked how large the administrative team was in the Health Visiting service, if this helped to drive efficiencies, and if there were any vacancies. The Associate Director of Operations CHS explained that administration was done by a team that oversaw several Public Nursing teams, and that a new performance manager was in post who was helping to drive new ways of working such as the digital offer. There was now a better weekly oversight of performance and improved admin flows, which helped to identify what was affecting performance in the service and to provide better challenge. There had been some long-term vacancies filled by agency workers, but the team was now fully recruited.

Members commented on the targets for one and two year checks, and suggested that these were not ambitious; it was asked what happened to families who were did not receive checks in the target period and whether they were still received a visit. The Deputy Director of Nursing at CHS explained that targets were set by the commissioning team or at a national level, and that all children were offered a check, even if this was outside of target timeframes. If children were ‘Universal Plus’, ‘Universal Partnership Plus’, subject to a safety plan or were a looked after child then they would be reviewed and followed up. The Director of Public Health highlighted the importance of timely visits, and the scrutiny the service received from the Children’s Safeguarding Board.

The Sub-Committee enquired how the recruitment of additional Band 5 Community Nurses was progressing, and heard that Kingston University was providing the training course for these staff from July 2023. There had been some cultural challenges for existing Health Visitors, but also acknowledgment that this was in the best interest of parents and families to ensure checks could be provided.

Conclusions

The Sub-Committee thanked the Chief Executive of CHS and Place Based Lead for Health, Deputy Director of Nursing at CHS, Associate Director of Operations CHS and Director of Public Health for attending the meeting, and for their open and honest answers to Members questions.

The Sub-Committee welcomed the offer from the Deputy Director of Nursing at CHS to shadow Health Visitors in their natural work setting, to gain insight into the daily experiences of staff.

The Sub-Committee concluded that Health Visiting should remain on the Work Programme for 2023/24, alongside the regular receipt of Quarterly commissioning data.

Members welcomed the commitment and willingness of Senior NHS colleagues to continue to work with and report to the Sub-Committee.

The Sub-Committee concluded that they would continue to monitor the visiting rates of the service throughout the year and would review the targets at a future date against the mean visiting rates for London boroughs in 2022/23 once these were available.

Recommendations

The Sub-Committee were of the view that a working group should be established to look at all possible incentives available to improve retention and recruitment in the Health Visiting service.

The Sub-Committee recommended that all available options to assist staff with housing, where this presented a barrier to recruitment and retention, were investigated.