Department of Health - 16.10.09
Burnham speech: Unite/CPHVA
It's a pleasure to join you at what is
something of a watershed moment - for the NHS, for public health,
and specifically for you, as community health professionals.
I want to begin by setting out what I see as the broad public
policy context.
We shortly begin a new decade, and a new era for the NHS. It
will be very different from the last - but one where we can make
potentially even bigger strides forward in the health of the
nation.
In the last 10 years, the NHS has done the heavy lifting,
tackling waiting and infections. It has gone from poor to good and
earned the right to focus on quality. In the next decade, I believe
it can go from good to great - preventative and people-centred in
all that it does.
For all its great strengths, the NHS in its first 60 years has
been too reactive, a 'pick up the pieces service' geared around
treating illness.
In the years ahead, we need a paradigm shift: a move away from
this traditional diagnose-and-treat model, and towards a
predict-and-prevent approach to health.
This means change, and money out of hospitals and into the
community. It means rethinking how we support people at the start
of their lives and the end of their lives, breaking the down the
barriers between health and local government.
And let me be clear from the outset: I see the professions
represented here today as the very forefront of this thinking, as
some of the few in the health system who reach out to prevent
rather than treat.
The next decade presents a huge opportunity to establish health
visiting and school nursing teams at the vanguard of a pre-emptive,
preventative health service.
This promise isn't a vague one - it's set out clearly in black
and white in the Healthy Child Programme, which will very shortly
be extended to cover from pregnancy right through to age 19.
The Healthy Child Programme is the vision, built on a sound
understanding of how we can support families and ensure the effects
of deprivation and disadvantage on young lives are minimised.
Health visiting teams, nursery nurses, school nursing teams are
fundamental to making it a reality.
As the leaders of this programme, it presents new opportunities
to make the difference to young lives. But that leadership position
is important for other reasons.
It more appropriately recognises your skills and abilities as
senior professionals, enhancing your job satisfaction today, and,
crucially, raises the status of community health as a profession
and career choice for the next generation.
But if the Healthy Child Programme is the vision and the
destination, then today's Action on Health Visiting programme is
the roadmap for getting us there.
It's a consensus, developed in close partnership with this
organisation, and with you the professionals.
It carries through the commitment Alan Johnson and Lord Victor
made six months ago, and I would like to thank all those who have
been involved in its production.
It provides the missing pieces of the jigsaw, the key things
you've been asking for.
Greater clarity in your roles. Greater confidence for the
profession. Measures to improve the training across all levels of
the workforce. And, yes, the first steps to reversing the long term
decline in health visiting numbers.
The Healthy Child Programme and Action on Health Visiting are
significant developments - our collective challenge is to make sure
they mark a genuine turning point for the health visiting
profession.
If that is to happen, I know it's important that we see real
change as quickly as possible and that we do all we can to overcome
the barriers you face today.
I know that many of you will feel that people like me have not
paid enough attention to health visiting, or fully appreciated the
difference it makes.
Well, I think that's a fair criticism so, in advance of today's
speech, I wanted to get a feel for what you're coming up against on
a day-to-day basis.
In both my stints in the Department of Health, I have made time
to go work shadowing but have admit that I haven't until now
shadowed a health visitor.
On Monday, I finally put that right and spent a couple of hours
in Leigh with an experienced health visitor covering areas of my
constituency with the greatest heath needs.
What struck me most is the very personalised nature of the
service, how - unlike other parts of the health service which are
trained to treat the immediate problem in front of them - you look
behind at the whole person, seeing the whole story, seeing and
responding to the determinants of poor health, not just the
symptoms.
It's a job that calls for versatility, flexibility and
resourcefulness.
It was only for a morning, but I saw a universal and a targeted
visit - and I understand now how both are utterly crucial in
stopping children falling through the net and, by getting to them
the specialist help they need (for instance, speech therapy or
mental health support), give all children a chance of fulfilling
their potential and break inter-generational cycles of poverty.
Let me tell you, as a Labour politician, absolutely nothing
matters more to me than helping the children who have least in life
go on to be the best they can be.
Your role in that is crucial, helping those dealt the toughest
hand of cards overcome the barriers in front of them.
It's this 'Sliding Doors' principle - that life can turn out
very differently from what can seem a small event - that puts
the spotlight on what's at stake here, and enables me to see
something that you know only too well - that families are a source
of resilience and risk, and a health visitor, working closely with
a family, is uniquely placed to see emerging problems with a
child's development, and uniquely skilled to lead a
multi-disciplinary response.
We tend to focus a lot on the moral arguments for these kind of
interventions, and rightly so. The work you do with vulnerable
families to tackle health inequalities and strive to give all
children the best possible start in life is fundamental to any
notion of a fair society.
But there is also a significant economic and public spending
question - because the 'what if' question carries a hefty price tag
for public services and for society.
If you look at the 2008 Think Family report, it suggests that
families with multiple disadvantages cost the state up to £115,000
a year.
The cost of supporting a child in care who has additional needs,
meanwhile, is almost £300,000.
To say nothing of the unquantifiable effects of failure. The
loss to the economy of poor qualifications and long-term
unemployment. The drain that a disruptive pupil puts on resources.
The damage that anti-social behaviour causes communities.
I'm not saying health visiting is a panacea - and we certainly
need to understand more fully what kind of interventions make the
biggest difference.
But I have no doubt that if we fully harness your skills, your
capacity to get in early, to draw down the specialist support and
to nip small problems in the bud before they escalate, then we can
really start to help people fulfil their potential and use public
money much better.
At a time when the NHS is primed for leaner times, and the
temptation is to cut back on services, it's an argument that needs
to be made very forcefully to local commissioners. Not just by me,
but by everyone in the room.
Of course, underneath all this, there is the serious issue of
safeguarding.
As Lord Laming made clear, we do need to address the numbers of
health visitors - something I will come on to in a moment.
He also flagged the need for more clarity about your roles, more
confidence in the profession and a greater investment in
training.
Today's launch of Action on Health Visiting programme has
already met many of the challenges that Lord Laming set us.
It also delivers two-thirds of the commitments set out by Alan
Johnson and Lord Victor in their joint statement. And it provides
the roadmap for the rest.
With this launch, we set off on an important journey. It marks
the end of the wilderness years for health visiting, and the
beginnings of a renewed drive to support and sustain you as key
practitioners in the new predict and prevent paradigm in the health
service.
First, the programme delivers much greater clarity in your
roles.
We've worked with you as a profession, and with your academic
and service colleagues, to deliver a clear, comprehensive
definition of the health visitor role.
And together we have set out the five key areas where you can
make the biggest difference, including in safeguarding and working
in partnership with other local services like Sure Start Children's
Centres.
So this is an unequivocal statement, that places health visiting
at the vanguard of preventative health, and leaving commissioners
in no doubt about the contribution you must make.
HEALTH VISITORS NUMBERS
Second, the big question.
How do we address the issue of caseloads and the number of
health visitors?
The Action for Health Visiting programme establishes this as a
priority, and sets out a plan of attack.
I think all of us recognise there's a long way to go. I don't
think anyone is in any doubt that this is a major challenge.
Stories of health visitors with caseloads of a thousand families
call into question the idea of health visiting as a universal
service for children and families.
The days of centralised mandates are over, so I'm afraid I'm not
going to stand before you and make another central target for the
NHS to reach.
It is right that PCTs decide where to prioritise funding - in
this region, the needs can differ greatly from one town to another.
The next era in the NHS will not be about top-down diktats but
reform led at the local local level by patients and staff.
So I am going to resist the temptation to talk in terms of
central targets. But what is non-negotiable is that every locality
must commission for a Health Child Programme that meets local
needs, and that health visitors will lead those teams.
As a result, there is a case to be made for more scrutiny over
the number of health visitors that Trusts employ.
So, if caseloads in a given area are high, then commissioners
should be making a clear and sensible explanation for why.
Today, therefore, I want to make three things clear.
First, in the wake of Lord Laming's report, we expect to see the
health visiting workforce increase markedly - and confirmation of
your lead role in delivering the Healthy Child Programme makes that
even more important.
Second, I want to see the variation in case load that health
visitors have in different Trusts narrowed significantly.
And third, I want to see investment in health visiting more
explicitly linked to levels of deprivation - and that's in
recognition of the fact that your work is particularly invaluable
in reaching out and supporting the most disadvantaged families.
How do we make sure this happens?
Well, in the long term, we'll be working with you to develop a
clearer evidence base that links to outcomes - that will present a
clear case that commissioners should follow.
In the meantime, to focus minds, I am today announcing that from
next year we will require PCTs to publish workforce and case load
figures.
This will allow primary care trusts to benchmark themselves
against comparable areas, and Strategic Health Authorities and the
national Nursing and Midwifery professional advisory body will also
use the figures to check that trusts have the right numbers of
health visitors and the right skills mix to meet the needs of their
population.
As I say, over the next few years, we will be moving towards
measuring outcomes and using that evidence base as the driver for
commissioning decisions.
Benchmarking is simply a bridge to this point, but I do think
the scrutiny and the insight it provides will be an effective
catalyst for change.
RAISING PROFILE
Hand in hand with raising numbers, we must also raise the status
of health visiting too - this was a third concern that was
registered both in Lord Laming's recommendations and in our joint
statement.
The starting point here is to make sure your clinical and
professional judgement is accorded the right degree of importance
across the children's workforce.
There is more we can do to bring the health service and
children's services together to act more preventatively and with a
greater sense of common purpose.
Your ability to be able to draw down specialist support is vital
for helping children and families, but too often gaps between
health visiting and social work service mean the latter are delayed
or not available.
Our health visiting and social work systems and thresholds must be
a much better fit, so that no health visitor feels they can't draw
down the support that a family needs.
This week Ed Balls and I will therefore be writing to the Social
Work Taskforce making that point clear, and asking them to look at
how we can encourage social workers to take a stronger preventative
role in partnership with health visitors.
We've got to get the system right everywhere, so it doesn't
allow families to fall through the gap.
We will also be looking closely at the performance of Children's
Trusts to ensure they commission the Healthy Child Programme in a
way that encourages better cross-agency working.
LEADERSHIP TRAINING
The final big challenge, linked to that last point, is
leadership and training opportunities.
I think we're all agreed that we need to strengthen the career
structure, so that we can attract and retain the top talent into
health visiting.
The joint statement again made it clear that providing more
training places was key, and Action for Health Visiting reinforces
this message.
We have already seen a welcome increase in training commissions
this year, building on the positive trends of recent years. Last
year, commissions went up by 61%, for instance - and we know they
have increased further still.
But if we are placing health visitors at the helm, then we
really do need to invest in your leadership.
That's why I'm pleased to say we are investing £2m this year to
develop multidisciplinary clinical leadership fellowships aimed at
enhancing the leadership skills of clinical staff.
This will include a particular focus on health visitors, nurses
and Allied Health Professionals and will help more you to access
these advanced fellowships.
On top of this, as part of the Transforming Community Services
programme, we're developing an e-learning programme for all
community practitioners to provide the skills you have told us you
need to work effectively in today's environment.
So the opportunities will be there. I expect local areas to
invest in your leadership - it's now up to you to step forward and
make sure that health visiting is at the forefront of the clinical
leadership fellowships.
Safeguarding - the Ian Kennedy Review
All of us, I know, are resolved to do everything humanly
possible to prevent the tragedy and the horror of the Baby Peter
case from happening again.
In response to the inquiry, David Nicholson has asked the former
chair of the Healthcare Commission, Sir Ian Kennedy, to undertake a
thorough review of NHS services for children.
Sir Ian will look at how we can build on the progress we have
made, putting on a spotlight on good practice, but also talking to
staff, children and families about how we can improve things in
future.
As part of his review, I would expect Sir Ian will make further
recommendations on how we can help community health professionals
work much more closely with other local services to further improve
safeguarding arrangements for children. I would welcome your input
to the review.
The wider role of community health professionals
I know I have spent quite a lot of time focusing on health
visitors. But I do also want to put a spotlight on other
professionals in the room today.
Because everything I've said about the prominence of health
visitors is equally true of other community health
professionals.
School nurses will be an increasingly important player as we
extend the Healthy Child Programme to older children later this
year - and again, that is a chance to place the role of school
nurses at the heart of a preventative NHS.
Occupational health nurses are already playing a big role in
achieving the ambitions of Working for a Healthier Tomorrow - Dame
Carol Black's 2008 report on the health of the working
population.
And at a time when this country is slowly emerging from the
shadow of recession, this is a particularly important role to play
in Britain's recovery.
Then, of course, there's the challenge of dealing with the big
lifestyle challenges - and here, community nurses are contributing
to the massive challenge we face in tackling obesity, smoking and
drink and drug abuse - all of which are storing up considerable
problems for the NHS into the future.
While your roles may differ, I know all of here are united by a
simple desire to do the very best for the children and families we
support.
Conclusion
To conclude, I know that some may be thinking that I haven't
gone far enough today on the issues that matter most, particularly
numbers.
I am always prepared to listen and go further where needed. But
I am saying very clearly today that we have set out from the centre
the tools you need to set up an exciting new era in community
health and health visiting.
My challenge to you is to make the most of them. The best
change is locally-driven and locally-owned. I know there are
already exciting things happening, not least in Leigh where
community health, social work and schools are joining forces in a
new family service.
But, where it's not happening, I say: don't wait for central
mandates. Get out there and make a noise, using all the tools we
have given you.
The wind is set fair for you to make your case, reverse the
decline in numbers and raise the status of a profession taking
centre stage in a preventative NHS.
We've got three years until 2012 - your 150th anniversary as a
profession. I hope you will leave this conference this week
resolved to use the intervening years to make it a celebration of
new beginning.
