serious stuff

October 24, 2004

Thanks . I agree that clients should have the right to complain and would hope that the issues will now be addressed in the area where the mother lives. But I do get worried when the whole profession seems to get tarred, as many HVs are doing innovative work as was seen at the conference.

I'm sure that mothers will start complaining soon in the area where I work as we've gone in recent years from what was a reasonable service, to, in my view, an abysmal one because of severe staff shortages. I'm already embarrased about having to keep apologising to clients for lack of staff -it sounds so feeble, although it's true. Just hope they write to management and not to the Journal!

Best wishes

June

October 24, 2004

Dear June, I can only echo your troubles, where in the country are you? It sounds like we could be consoling ourselves jointly, but continuing to do what we know works. Kathy Soderquist

October 27, 2004

Dear

What an excellent email.

I espy love the elasticated trousers and a

firm focus!

Marx and Sparks?

VBW

Chris

www.primhe.org

From:

Daly [mailto:m_daly@...]

Sent: 27 October 2004 18:21

Subject: Re: serious

stuff

Thank you . I have known for some time there are

unpleasant home truths Health Visiting has to face regarding our public image.

A straw poll amongst my colleagues recently elicited the following, five

out of six in the team have been consumers of health visiting over a period of

25years. All of us have had poor experiences including myself. four of

us have taken action to avoid the Health Visitor. This totally

unscientific lunchtime conversation is familiar.

The three greatest influences on my practise have been 1.

Becoming a mother myself. 2 The media training I recieved and practised whilst

working as a professional officer at the Former HVA. It is extrordinary

how often we speak in a language made up of medicalese, psychologese and

sociologese. I was thought to give answers in soundbites in plain

english. The marketing training I received whilst working in industry

really focused my attention on the customer, One of my responsibilities was to

oversee the free-phone line. That was also a sobering experience. When it

was suggested to customers they contact their health visitor a common response

was " I know more about nutrition than she does that is

why I have called you " .

We need to humbly ask ourselves what it feels like to be on

the receiving end of an EPDS or the other needs assessment tools . I observed

my husband squirm with embarassment recently when confronted with a needs

assessment tool his embarassment was reflected on the face of the unfortumate

nurse conducting the interrogation. Families especially are unclear

about how much power we have and what risk we pose to them at a time

of great vulnerability and stress for them.

On the other hand I have been looking at what happens to

families who get by-passed by the health visiting service and it is not

difficult to demonstrate that we are the core service, and that children suffer

in a measurable way if we are not there for them. In another completely

unscientific survey I have looked at the amount of DLA lost by children who

received poor or inadequate health visiting. Amounts up to £40,000

pounds were lost. There is no other worker to helicopter manage the complex

needs of families, without the health visitor services are fragmented and

families left to chance.

Our profession is a delicate balance of support and

supervision we must listen to our clients and retain their trust. We must

also deliver to them by addressing their expressed needs and working alongside

them as they find solutions I like the idea I read somewhere recently of the

Health Visitor as Family Coach. I sometimes think we a re a bit like Marks

and Spencer solid but not so customer focused, lots of good things but they are

difficult to find under the mountains of elastocated trousers. but totally

capable of transferring itself into a 21st Centuray company with a lfirm focus

on customer aspirations

Daly

---- Original Message -----

From: Cowley

Sent: Wednesday, October

27, 2004 4:26 PM

Subject: Re:

serious stuff

and , like you I was deeply upset when I first read the AIMS

article. It reminded me of the one and only time that, as practitioner, I

had a client who had never met me, refuse to have a health visitor.

I did think that the mixture of rejection, injustice and grievance that I

felt at the time was probably the nearest I would ever to get to an insight

about how awful it must feel to be on the receiving end of racism: I was

desperate to say: but you don't even know me, I'm not like you think I

am, and health visiting is not what you think, either. But of course, I

did not know what she thought, or what had happened in her life to make her

reach (what seemed to me) to be a very negative conclusion. It was her

right to refuse the service. I eventually met her, briefly, when she

brought her (very healthy) child to be weighed at a baby clinic many months

later, but did not revisit the issue. People reach the conclusions they

do precisely because they are looking at things in a way that is unique and

individual to them. Sometimes, when we have an insight into that way of

thinking, we are in a position to say: " I had never thought of it

that way. Have you ever considered this or that way of looking at

it? " At other times, we have to accept that people all have very different

perspectives on issues. Generally they have that right; we may profoundly

disagree, but it may be how they survive difficult situations. Very

occasionally, as a profession, we can take heed of warnings about

misunderstandings that we might avoid and I think this such a warning.

AIMS is renowned for being a radical campaigning organisation, on behalf of

pregnant women and mothers, which does mean they put their clients (members)

views ahead of those offered by professionals. I cannot say, when we met

and Beverley, that they seemed either deeeply antagonistic to health

visitors, or to be generally at all unreasonable. Nor were they reacting

to a single or small number of complaints: it was a long litany, with a

marked increase in recent years. We had a long discussion about the

different perspectives that arise within child protection, and the great

difficulties that arise when parents deny that their behaviour is damaging to

children. We talked at length about the recent tragedies:

Climbie at the top of the list, whose carers successfully assured professionals

that the child was the problem. But, set against that, we only have

to look at the recent court decisions around infant deaths (Sally e,

Trupti Patel etc) to see that this is not a one sided story:

professionals get it wrong in both directions. The challenge in

health visiting is that we have to get bioth directions right. We are, in

effect, social police, even if we hate that description. How else are

vulnerable children, victims of domestic abuse etc., to be protected or to get

a voice? But we are also there to support and help, not to judge or

blame. It is very difficult to achieve a positive balance and a very hard job

that needs enormous skill.

and Beverley were mystified about what had happened to change health

visiting over the last seven to eight years, and the only explanation they

could reach, faced with a long list of people who had faced both ignorance, and

intrusive, unpleasant questioning by health visitors, was the 'harvesting

babies' one. They said they had had no success in contacting professional

organisations (RCN, CPHVA and NMC): perhaps they did not reach the

right people or try hard enough, or perhaps those they contacted refused to

engage with them, believing them to be troublemakers. Who knows? We

said very clearly that we did not think that any health visitor would be

engaged, even unconsciously, in any activity designed to increase babies

available for adoption, but it was the explanation they had reached in their

minds. It allowed them to make sense of what seemed to them, otherwise,

to be inexplicable behaviour on the part of the professionals.

We also know from masses of research with women who have been on the recieving

end of questions from health visitors, that they commonly ask: why is she

asking me that? What have I done to make her think she needs to ask me

that question? What is she going to do with that information? There

has also been a long standing fear, reported in the literature, that " they

will take their baby away from you, if you don't toe the line " . The

'harvesting babies' terminology is just a new (and extreme) manifestation of

this anxiety. The idea of health visiting being like an offer of help

from the Mafia, because you cannot refuse it, rang horrible bells with me, too.

In all the (masses!) of needs assessment research I have done, even where

it is explicitly Trust policy that clients do not have to participate, they are

either not told of that choice, or not told their needs are being assessed, so

they are denied any effective choice. Of course, effectively health

visitors cannot give a choice, because the whole service is based on the

assumption of needs assessment, now, not of universality!

I think (and have posted masses of papers to about this)

that most health visitors do, as you indicated , try to be very sensitive

and avoid intrusive and unpleasant questions. I think they also try to

provide a universal service, to avoid the stigma, anxiety and misunderstandings

caused by 'singling out' individuals for a service. But it is an uphill

battle in the face of insistence on use of explicit needs assessments

schedules and the 'targeting tools' beloved of management.

The paper that Jan Mitcheson, Houston and I had published in

Sociology of Health and Illness is the only one, as far as I am aware, that

specifically documents any resistance to these techniques by health visitors,

although Jane Appleton has also recorded that health visitors largely ignore

the official guidance, so they can make more sensitive, individually focused

and personally tailored professional judgements (which are very complex and

difficult: back to my gripe about inadequate training!). But even though

we have grumbled a lot in private, as a profession, we have not made a habit of

making public our concerns about the stigmatising impact of of

non-universality, or of targeting procedures. Perhaps we should.

But how would we do that?

Or, do we just ignore the complaints as unreasonable, and carry on as if they

have not happened? best wishes

Tom Lund-Lack wrote:

Hear, hear .

I was so taken aback at the tone of the article it's taken

me a few days to collect my thoughts and make a rational response to an

irrational piece of work. I can't understand why she hates us with

such a passion. Is there a personal agenda in all this? She has heard

some stories but has only heard one side. I had a client who was featured

in a weekly national women's magazine some time ago who related her tragic

story and you would think that she was some kind of martyr to the system.

Far from it. The family caused deliberate criminal damage to property, lied to

professionals and were generally very troublesome. The article made her

out to be a saint. There is a element to some women's organisations that

seem to feel threatened by the health visiting service and it is hard to know

what feeds this aversion. There is a very right and proper debate led by health

visitors about the nature of their relationship with clients and the honesty

about what we set out to do. Most health visitors are very concerned that we

are not some kind of health police. refers to Jan

Mitcheson's research into the use of screening tools and their acceptability to

clients. Jan was my research supervisor when I did some further research about

the perceptions of health visitors about the use of an antenatal screening tool

that we use locally and every health visitor I interviewed stated they were

concerned about intrusiveness and that trusting relationships are built over a

period of time and have to be very sensitively developed. Remarks about

'harvesting of babies by health visitors' is almost slanderous. To which

audience is hoping to spread her remarks. I hope it doesn't include

vulnerable parents because she could seriously increase the risks they and

their children face if they are poisoned against us.

On a general note I think it is worth reflecting that possibly

the wider governmental agenda is turning us into quasi social workers and that

label does not do the profession any favours. We must stick to our

preventative and health promotional role.

Lund-Lack

Re:

serious stuff

, I found these complaints quite shocking to read when I had just

returned from CPHVA Conference and felt so

inspired by many of the

practitioner presentations which highlighted some

amazing practice. This

article seems very unbalanced and appears to have

only searched for bad

examples without looking at examples of good

practice as well. Certainly

there is room for improvement from all

practitioners in all areas of

practice and perhaps it would be helpful to

consider some collaborative

approaches in order to support improvements rather

than picking on and

accusing our colleagues in this very negative way.

Hayward

October 28, 2004

Hi

I was interested by your response and

agree with the comments about health visitors thinking they shouldn’t

work in partnership with families but be in charge. It’s very difficult

to change attitudes in those that feel like that about their role. I’ve

worked with the South Fenland Sure Start Programme

for the past 4 years and see how effective partnership working can be. I also

agree with the health visitors in the North East about the usefulness of a

systematic process for carrying out visits. We have an electronic health needs

assessment process in North and South Fenland which has

built into it nationally validated screening tools such as the EPNDS score. It’s

been recommended in the NSF for Children that families receive a holistic

family health assessment at least ante-natally, at 1

year and perhaps between 2 and 3 years. If the information has been captured

electronically each family gets a similar approach from their HV, it avoids

repetition at subsequent assessments which might be carried out by a different

health professional, and it avoids recall bias by capturing the data at the

time of the discussion with the family. These assessments do not take away from

the importance of listening but prompt a fuller systematic discussion. We prioritise the discussion over the collection of data, The anonymised data can then

be analysed exposing gaps in services which informs

the PCT Local Delivery Plan for future years. How will the HV discussion inform

future needs if it’s in paper records or in someone’s head? We will

have a completed evaluation of our HNA process in the next couple of weeks. It

has been commissioned from a company who have carried out

a lot of evaluation for Sure Start Programmes nationally

and we will be happy to share the summary with anyone who is interested.

Penny

Re:

serious stuff

Yesterday I e-mailed the chair of AIMS to lodge my dismay at the

article. Their web page states that they support professionals!! Kathy

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October 28, 2004

Are there any data on whether the profile of applicants to HV has

changed in the last few years? Chris's examples indicate some

very strange practice.

Professor Liz Meerabeau

Head of the School of Health and Social Care

University of Greenwich

Avery Hill Campus

Southwood Site

Avery Hill Road

London SE9 2UG

020 8331 9150

020 8331 8060 (fax)

E.Meerabeau@...

October 28, 2004

Dear Penny,

I am sure that we do need to make a systematic collection of data. It is the processes by which this done which is in question. Are parents fully informed that the assessment is taking place? Are questions explained with reasons given for them being asked? Are health visitors then trained as to how to respond to the answers or is it a tick-box exercise? I think I was saying that if there was training in core communication skills initially in HV courses then this would not be so problematic.

There are serious constraints on health visiting practice at present. What I am frequently told by health visitors is that they do not have the time that is needed to interact with clients by listening carefully. Their nursing background teaches them to solve problems. They hear an initial problem and right away offer advice on how it should be dealt with because it takes longer to hear the full picture. During training we have discussions around this issue and usually it is acknowledged that it might be more effective to hear the full story first so as to know exactly what the client is dealing with so that together they can come up with some workable solutions if that is what is required. Of course, some problems or issues do not require solving but a supportive alongsidedness that health visitors might be able to provide.

There is a serious lack of health visitors out there and unless we address this issue as well then the pressures that health visitors feel to solve problems and beat a hasty retreat will remain, I fear. According to the national census site in 2003 the number of births was 621,548. The number of WTE health visitors in 2003 was 9,999 according to the DOH.

This means that if all those registered as health visitors were working in the traditional role then each health visitor would be doing approx. 62 new births a year. On paper this seems quite manageable until you realise of course that health visitors have holidays and many are not in traditional roles. Hopefully and colleagues at Kings will have some light to shed on the true state of affairs in the not too distant future. Certainly I heard recently of a health visitor trying to cope with 20 new births in a week! The pressure to get them done might very well have interfered with her communication skills, don't you think?!

Best wishes

- Original Message -----

From: Penny

Sent: Thursday, October 28, 2004 11:00 AM

Subject: RE: serious stuff

Hi

I was interested by your response and agree with the comments about health visitors thinking they shouldn’t work in partnership with families but be in charge. It’s very difficult to change attitudes in those that feel like that about their role. I’ve worked with the South Fenland Sure Start Programme for the past 4 years and see how effective partnership working can be. I also agree with the health visitors in the North East about the usefulness of a systematic process for carrying out visits. We have an electronic health needs assessment process in North and South Fenland which has built into it nationally validated screening tools such as the EPNDS score. It’s been recommended in the NSF for Children that families receive a holistic family health assessment at least ante-natally, at 1 year and perhaps between 2 and 3 years. If the information has been captured electronically each family gets a similar approach from their HV, it avoids repetition at subsequent assessments which might be carried out by a different health professional, and it avoids recall bias by capturing the data at the time of the discussion with the family. These assessments do not take away from the importance of listening but prompt a fuller systematic discussion. We prioritise the discussion over the collection of data, The anonymised data can then be analysed exposing gaps in services which informs the PCT Local Delivery Plan for future years. How will the HV discussion inform future needs if it’s in paper records or in someone’s head? We will have a completed evaluation of our HNA process in the next couple of weeks. It has been commissioned from a company who have carried out a lot of evaluation for Sure Start Programmes nationally and we will be happy to share the summary with anyone who is interested.

Penny

-----Original Message-----From: Bidmead [mailto:christine@...] Sent: 28 October 2004 10:13 Subject: Re: serious stuff

I have been giving some careful consideration to the questions raised in the AIMS newsletter which is why I have not jumped in until now. I think it is right and proper that parents complain when they feel abused and let down by the system. I for one have been aware that all has not been well in health visiting for some time as I have been working with groups of health visitors across the UK (training parent advisor/family partnership model).

Here is an example of the response of a recently trained health visitor. In a seminar on the kind of relationship a health visitor seeks to have with a client where we agreed (I thought) that partnership might be the most effective relationship a health visitor might have, a participant piped up in absolute horror 'but the client might become more powerful than we are!' The very fact that we are seeing this public backlash on health visiting reminds me that an authoritarian approach in parenting brings about the same rebellious and outspoken responses from teenagers. The very fact that as a profession we are being seen as the 'health police' and authoritarian in its approach needs someone to say 'enough is enough!'

Here is another example of a health visitor response to a short listening skills practice, 'I don't do psychological'. These are exact words from a recently trained health visitor. What did that mean? It meant that she felt that listening closely to what the client was saying and responding appropriately was too intense a way of interacting. Another health visitor told me that she was afraid to work too closely with clients as she may detect more problems about which she unable to do anything especially post-natal depression due to lack of time and pressure of work. I found this alarming to say the least.

These sort of examples are balanced however, by some pockets of absolutely excellent practice where the more inexperienced health visitors are well supported by their more experienced colleagues. Some very experienced health visitors who take part in the training do already have very well developed communication skills and are an absolute delight to work with and make me feel proud to be a health visitor. This type of training in core communication skills needs to be a part of every health visitors basic training. How can we make this happen? Any suggestions welcome.

At the CPHVA conference I heard a presentation regarding the introduction of a health needs assessment tool in the North East. I was sceptical at first but as the presentation went on I was impressed by the sincerity of the health visitors and their efforts to evaluate its effect on parents. They insisted firstly that the tool was not used at a first visit, believing that the relationship with the client was the most important thing to get right first. They also insisted that it was not a checklist and that the clients points were important to be responded to. It was also stressed that the tool could not be used without adequate training in its use. It was an aid to a guided conversation with clear explanations being given along the way as to why certain areas might need to be touched on. What bothered me most was that at the end of the presentation the health visitors in the audience descended on the presenters to get a copy of the tool as if it were a magic potion that would allow them to discover what had as yet been undiscovered. I still feel however, that if we train health visitors to communicate adequately we would not need to train them how to ask questions that need to be asked.

Unusually I am going on a bit but I am quite fired up by this discussion that has been ongoing over the last few days. Finally, again at conference I met Sally , Director of Netmums. More positively than all that has gone before in this discussion she would like to work with us (SIG for Parenting and Family Support) to support health visiting. The research carried out by her organisation found that 54% of parents would turn to a health visitor for advice on parenting issues but only 15% would talk to a health visitor if they 'felt down'. This calls into question the use of the EPDS. Is it being used? Is it being used properly? I have heard a health visitor say that she didn't actually believe the high scoring result that she had from one client and thought she was telling 'porkies' to get better housing!

So all in all there are some worrying things going on out there in practice. However, as I know from the SIG group, and Senate there are also many brilliant things and some very skilled practitioners. Like the curate's egg it is good in parts. Somehow we need to get the training right so that we include the core communication skills.

Best wishes,

Re: serious stuff

Yesterday I e-mailed the chair of AIMS to lodge my dismay at the article. Their web page states that they support professionals!! Kathy

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October 28, 2004

Dear

I appreciate the shortage of HVs which is why partnership working is so important. We

have quite large caseloads, especially in North Fenland, with

complex family dynamics requiring skilled assessments, with supervised

delegation of work to other team members (staff nurses, nursery nurses and

assistants). The team skill mix seems to work very well and we are growing new

health visitors as a result, from the existing staff.

Penny

Re:

serious stuff

Yesterday I e-mailed the chair of AIMS to lodge my dismay at the

article. Their web page states that they support professionals!! Kathy

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October 28, 2004

I would be grateful to see the evaluation Penny.Ann

Ann Ebeid

>From: " Penny " <penny@...>

>Reply-

>< >

>Subject: RE: serious stuff

>Date: Thu, 28 Oct 2004 11:00:17 +0100

>

>Hi

>I was interested by your response and agree with the comments about health

>visitors thinking they shouldn’t work in partnership with families but be

>in charge. It’s very difficult to change attitudes in those that feel like

>that about their role. I’ve worked with the South Fenland Sure Start

>Programme for the past 4 years and see how effective partnership working

>can be. I also agree with the health visitors in the North East about the

>usefulness of a systematic process for carrying out visits. We have an

>electronic health needs assessment process in North and South Fenland which

>has built into it nationally validated screening tools such as the EPNDS

>score. It’s been recommended in the NSF for Children that families receive

>a holistic family health assessment at least ante-natally, at 1 year and

>perhaps between 2 and 3 years. If the information has been captured

>electronically each family gets a similar approach from their HV, it avoids

>repetition at subsequent assessments which might be carried out by a

>different health professional, and it avoids recall bias by capturing the

>data at the time of the discussion with the family. These assessments do

>not take away from the importance of listening but prompt a fuller

>systematic discussion. We prioritise the discussion over the collection of

>data, The anonymised data can then be analysed exposing gaps in services

>which informs the PCT Local Delivery Plan for future years. How will the HV

>discussion inform future needs if it’s in paper records or in someone’s

>head? We will have a completed evaluation of our HNA process in the next

>couple of weeks. It has been commissioned from a company who have carried

>out a lot of evaluation for Sure Start Programmes nationally and we will be

>happy to share the summary with anyone who is interested.

>

>Penny

>

> Re: serious stuff

>

>I have been giving some careful consideration to the questions raised in

>the AIMS newsletter which is why I have not jumped in until now. I think

>it is right and proper that parents complain when they feel abused and let

>down by the system. I for one have been aware that all has not been well

>in health visiting for some time as I have been working with groups of

>health visitors across the UK (training parent advisor/family partnership

>model).

>

>Here is an example of the response of a recently trained health visitor.

>In a seminar on the kind of relationship a health visitor seeks to have

>with a client where we agreed (I thought) that partnership might be the

>most effective relationship a health visitor might have, a participant

>piped up in absolute horror 'but the client might become more powerful than

>we are!' The very fact that we are seeing this public backlash on health

>visiting reminds me that an authoritarian approach in parenting brings

>about the same rebellious and outspoken responses from teenagers. The very

>fact that as a profession we are being seen as the 'health police' and

>authoritarian in its approach needs someone to say 'enough is enough!'

>

>Here is another example of a health visitor response to a short listening

>skills practice, 'I don't do psychological'. These are exact words from a

>recently trained health visitor. What did that mean? It meant that she

>felt that listening closely to what the client was saying and responding

>appropriately was too intense a way of interacting. Another health visitor

>told me that she was afraid to work too closely with clients as she may

>detect more problems about which she unable to do anything especially

>post-natal depression due to lack of time and pressure of work. I found

>this alarming to say the least.

>

>These sort of examples are balanced however, by some pockets of absolutely

>excellent practice where the more inexperienced health visitors are well

>supported by their more experienced colleagues. Some very experienced

>health visitors who take part in the training do already have very well

>developed communication skills and are an absolute delight to work with and

>make me feel proud to be a health visitor. This type of training in core

>communication skills needs to be a part of every health visitors basic

>training. How can we make this happen? Any suggestions welcome.

>

>At the CPHVA conference I heard a presentation regarding the introduction

>of a health needs assessment tool in the North East. I was sceptical at

>first but as the presentation went on I was impressed by the sincerity of

>the health visitors and their efforts to evaluate its effect on parents.

>They insisted firstly that the tool was not used at a first visit,

>believing that the relationship with the client was the most important

>thing to get right first. They also insisted that it was not a checklist

>and that the clients points were important to be responded to. It was also

>stressed that the tool could not be used without adequate training in its

>use. It was an aid to a guided conversation with clear explanations being

>given along the way as to why certain areas might need to be touched on.

>What bothered me most was that at the end of the presentation the health

>visitors in the audience descended on the presenters to get a copy of the

>tool as if it were a magic potion that would allow them to discover what

>had as yet been undiscovered. I still feel however, that if we train

>health visitors to communicate adequately we would not need to train them

>how to ask questions that need to be asked.

>

>Unusually I am going on a bit but I am quite fired up by this discussion

>that has been ongoing over the last few days. Finally, again at conference

>I met Sally , Director of Netmums. More positively than all that

>has gone before in this discussion she would like to work with us (SIG for

>Parenting and Family Support) to support health visiting. The research

>carried out by her organisation found that 54% of parents would turn to a

>health visitor for advice on parenting issues but only 15% would talk to a

>health visitor if they 'felt down'. This calls into question the use of

>the EPDS. Is it being used? Is it being used properly? I have heard a

>health visitor say that she didn't actually believe the high scoring result

>that she had from one client and thought she was telling 'porkies' to get

>better housing!

>

>So all in all there are some worrying things going on out there in

>practice. However, as I know from the SIG group, and Senate there are also

>many brilliant things and some very skilled practitioners. Like the

>curate's egg it is good in parts. Somehow we need to get the training

>right so that we include the core communication skills.

>

>Best wishes,

>

> Re: serious stuff

>

>Yesterday I e-mailed the chair of AIMS to lodge my dismay at the article.

>Their web page states that they support professionals!! Kathy

>

>--

>This email has been verified as Virus free

>Virus Protection and more available at http://www.plus.net

>

October 28, 2004

Thanks Ann. I'll make a note in my diary and send it to you as soon as I receive

it.