“Health visitors give advice, they don’t judge, they help out.” – David Cameron.
“A health visitor is someone who would have liked to be a paediatrician, but for whatever reason, decided that she likes being out and about in the community, offering pearls of wisdom to as many poor, unsuspecting mothers as possible.” – Mumsnet Mum.
Before I begin this article I would like to offer a disclaimer. There are many knowledgeable, non-judgemental health visitors operating contemporary, however the growing trend is sadly that health visiting is attracting more complaints from mothers than ever before (Poulton. B). This article unearths the emerging reality behind the profession. I will tackle the following questions: How do you become a health visitor? How much do health visitors earn? Why does advice differ so dramatically between health visitors? And perhaps most importantly, what are my rights and how do I complain when a health visitor oversteps the mark?
A health visitor is a qualified nurse or midwife who has undertaken further training in child health, health promotion, public health and education. They work as part of a primary health care team assessing the health needs of individuals, families and the wider community. In theory, health visitors aim to promote health and prevent illness by offering practical help and advice. The service is distinctive from other health services in that it is supply rather than demand-driven so health visitors will contact clients whether requested or not (Heritage. J). The origins of the health visiting service lay in the sanitation movement of the nineteenth and early twentieth centuries. Strongly interventionist and targeted at working class homes, inspections of sanitation were carried out to “direct the attention of those they visit to the evils of bad smells, want of fresh air and impurities of all kinds” (The rule book of the Manchester and Salford Sanitary Association c1880).
Contemporary UK law does not recognise health visiting as a profession. Its status as a profession was removed from law ten years ago. The occupation has no legal standing and its title has no official meaning. This, argues Nursery World, “puts the public at risk” (Nursery World 2010). The legal change has made it easier for primary care trusts to cut back on health visitors and employ less qualified staff. In theory, anyone can describe themselves as a health visitor. This is legally acceptable.
In order to become a health visitor, a person should first be a qualified and registered nurse or midwife. To train as a nurse, a person will need to complete a degree or diploma. Five GCSEs (or equivalent) are required for entry onto a diploma course, and two A-levels/Highers (or equivalent) are required for degree programmes. A degree in certain subjects may allow a person to take a shortened training course.
Then the candidate should take a one year health visiting course at degree level. Courses may be completed in a shorter period where credit is given for prior experience. The requirements for entry to the course are very flexible and there is no minimum experience requirement; thus, someone who has not long worked as a nurse/midwife can become a health visitor.
Health visitors are paid on Band 6 of the NHS pay scale – i.e. newly qualified entrants normally start at £24,831, rising to £33,436 with seniority. Team managers and health visitor specialists can earn up to £39,273 per year on Band 7 of the NHS pay scale.
The sinister side of health visiting
Health visiting is an oxymoronic dichotomy. That’s just my fancy way of saying that the values of health visiting are in conflict with each other. On one hand, health visitors are required to give support to new mothers. This is the common reputation enjoyed by health visitors. Yet on the other hand they are required to place the same mothers under automatic suspicion of child abuse, erring on the side of caution at all times. Yes – child abuse. This is serious business. Commonly thought to be the exclusive domain of social services and the NSPCC, a central role of health visitors is to sniff out potential child abusers. Your friendly neighbourhood health visitor likes to do a James Bond and collect covert information on unsuspecting parents.
One example is the assessment for postnatal depression (PND). A diagnosis of PND used to be rare however now health visitors are required to screen all mothers for it using the (non-validated) screening tool: the Edinburgh postnatal depression scale (Cox et al). Developed in 1987, this rigid instrument emphasises the significance of professional lead, instead of client participation (Mitcheson. J). It consists of 10 statements, such as “I have felt sad and miserable” or “I have felt scared and panicky”. Common feelings for new mums adjusting to the hormonal, emotional and practical changes a new baby can bring, are often pathologised. This means that more new mums than ever before are having the PND label stamped in their records. Rather than this leading to greater support, it has “more to do with problematising parents and their relationships with children” (The Guardian). The consensus amongst health visitors is that a depressed parent can pose a risk to a child. An overwhelming number of mothers are aware of the association between a diagnosis of depression and assumptions of parenting incompetence. “Always put mascara on before the health visitor is due to visit. That way, she’ll think you’re coping and leave you alone” one journalist mother advised (The Wiltshire Gazette and Herald).
Also don’t go thinking that because you’re mentally sane you can limbo under the radar. Even if there is no depression or other ‘problems’ health visitors screen all new parents for any likely risk of child abuse. In some areas, they even visit mothers before the birth to do so. Intentionally vague and probing questions are rattled off, such as “How loving do you feel towards your baby/child?” and “How confident do you feel being a parent?” Such questions are designed to catch mothers off guard and although some health visitors attempt to distance themselves from the procedure by attributing it to a higher authority, the questioning creates an unnecessary climate of judgement (The Guardian).
“The screening looks at risk factors such as the mother’s age, marital status, education and whether the baby was premature or in special care. Many of these ‘risk factors’ are related to poverty, so just being poor makes labelling more likely” (Robinson. J). Mothers with physical problems are additionally picked up by the radar, so having a disability also makes labelling more likely. “Alternative lifestyles or ‘non-compliance’ of any kind may be regarded with suspicion – including breastfeeding toddlers, use of alternative practitioners and rejection of immunisation” (Robinson. J). These crunchy mothers undermine and challenge a health visitor’s authority, as that authority is derived from their mainstream textbook training.
Furthermore, health visitors purposely obscure their agenda from those they visit (Cowley S et al. Structuring health needs assessments: the medicalisation of health visiting). Vague smokescreen justifications are given for visits, such as “we want to get to know you before the baby arrives” and “we only want to know the depth of your problems so we can help”. The purpose of the interview is disguised. As well as the Edinburgh scale and interviews health visitors utilise cold calling (dropping in unannounced) and even more subtle techniques such as asking to use the bathroom so that they can snoop around. (Crap. I knew I should have removed the cat hairs from the sink).
Risk-assessment measures are increasingly used to pass judgments, and exploited retrospectively to justify past decisions and actions (Goddard C et al. Structured risk assessment procedures: Instruments of abuse? Child Abuse Rev; Openmarket). This increasing involvement in child protection threatens the ethical basis of health visiting (Taylor. S and Tilley. N). Is it ethical for health visitors to seek out and identify risks that they cannot effectively treat? “We cannot ask our Health and Social Services to act as a kind of anti-abuse intelligence service, smelling out the bad parents long before they have committed any crime” (Barker W. Practical and ethical doubts about screening for child abuse). The paradox is that when a mother is threatened with Social Services for “refusing” help, they are then seen as a risk when they “accept” help.
What is more, the Government’s campaign for disallowing aggression towards NHS staff has encouraged staff to label clients as “aggressive” when they have felt threatened, despite what constitutes aggression and threat being highly subjective. You don’t have to issue a bitch slap for your behaviour to be interpreted as aggressive. Vehemently disagreeing with your health visitor could also constitute aggression. A mother who receives a label of “aggressive” is seen as posing a risk of future child abuse. Health visitors’ tendency towards oversensitivity in this way is partly explained by their training background. If they trained as a nurse their approach can be excessively dogmatic.
Once a mum is labelled as suspicious by a health visitor, her label is transferred, via her records, to all the other Primary Care Trust staff that she may come into contact with during the entire course of her mothering experience. Like garlic breath, the label will follow her everywhere and infect her interactions with: midwives, GPs, paediatricians, nursery nurses, Sure Start centre staff, other health visitors and baby clinic staff.
In my opinion new parents should be seen as potentially vulnerable, rather than potentially abusive, and the aim of visits should be to strengthen the parent-child relationship. Yet instead mothers’ are disappointed that health visitors are largely there for the baby, not for them.
This climate of surveillance rather than support often makes mothers reluctant to request advice for fear that adverse judgements may be made about their knowledge or competence as a parent. These fears are justified by studies which have shown that health visitors show little effort in acknowledging mothers’ competencies and capacity for personal decision-making (Heritage. J). In situations where mothers assert their knowledge or competence, their assertions receive no acknowledgement or quasi-acknowledgement and, in a number of cases, are positively resisted (Kendall. S). Woe betide you mention opening a book or a laptop every once in a while.
Perhaps the most common way health visitors undermine mothers’ competence is by forcing unsolicited advice upon them. As is the case with mothers in law, the majority of advice given by health visitors is uninvited (Heritage. J ). Unlike mothers in law however, you can’t tell a health visitor that their advice is bollocks because due to their status as childcare professionals, their advice is commonly perceived as effectively unchallengeable.
The tendency of health visitors’ to trot out unrequested advice like an audio-wikipedia may be explained, again, by their nursing background. This training inclines them towards “an identification, diagnosis and treatment” approach to mothers rather than one in which mothers are encouraged to take the lead in defining their needs (Heritage. J).
As health visitors are lone workers and home visits are hidden from public view the health visitor has little fear of scrutiny. Foster and Mayall have observed that health visitors are confident in the superiority of their own knowledge base regardless of whether its origins are lay or professional in character. It is not uncommon for health visitors to dish out patronising, outdated and sometimes hazardous advice. Their excessively authoritarian attitude leads to mothers’ confidence being undermined on the rare occasions that they have some. One only needs to Google “health visitors” to read innumerable complaints from mothers about disparaging comments regarding delaying weaning until 6 months, about whether their babies are getting enough while only breastfeeding, whether mothers should/shouldn’t put their babies on a routine and a whole host of developmental issues where mothers have been happy with their choices prior to the visit but discouraged and undermined afterwards. Then, just when a mother assumes all her choices are ‘wrong’, she hears from friends that the same health visiting team is undermining her friends’ completely different choices.
Inaccurate and inconsistent advice damages trust and makes mothers reluctant to ask questions or act on advice given. These experiences and their repercussions are particularly alarming when one considers the fact that health visitors act distinctly different during home visits when the mother is alone than when third parties (husbands, grandmothers, friends) are present (Heritage. J).
There is perhaps no greater example of a health visitor’s potential for giving worryingly damaging advice than the area of breastfeeding. If you ask a first time mum with a newborn where she should go for breastfeeding advice, the little lamb’s first answer is likely to be “health visitor”. However the most common complaints the Association for Improvements in the Maternity Services receive are regarding health visitors’ ignorance and misinformation about breastfeeding – “and it’s getting worse” (Robinson. J).
The role of health visitors in facilitating successful breastfeeding relationships should not be underestimated. Studies have shown that “infants being breastfed at the first health visit were significantly more likely to be fed formula at the second visit if their health visitors had had no breastfeeding training in the previous two years” (Tappin et al).
Organisations such as UNICEF have found that the training health visitors receive in breastfeeding is woefully inadequate (No shit Sherlock?) Training is likely to be brief, and is often given by professionals from bottle feeding industries who have a vested interest in promoting their products (The Guardian).
When a breastfeeding problem is encountered, no matter how small, the overwhelming response from health visitors is – yes you guessed it – “top up with formula” (The Guardian). This strategy is used by health visitors in an effort to increase the agreeable appearance of the baby’s weight chart – and to cover their own backs. The weight chart is given preference over the holistic health of the baby. This botched order of priorities has been recognised by academics and commentators including renowned paediatrician Dr Jay Gordon (Look at the Baby, Not the Scale). He argues that “if someone were to ask you what weight a 33 year old man should be, you would laugh. The range of possibilities varies according to height, bone structure, ethnicity and many other factors. Yet babies are expected to fit onto charts distributed throughout the country with no regard to genetics, feeding choice or almost anything else.”
If there are breastfeeding problems, the first answer should never be supplementation as this will sabotage the nursing relationship by reducing milk supply and also damage your baby’s fragile virgin gut. Instead the correct advice would be to find the most knowledgeable support available; and herein lays the problem. Many health visitors see referral to appropriate specialist as a weakness in themselves. Rather than recognise their limitations, they obscure their ignorance by giving questionable advice. This situation is exacerbated by articles in childcare books, baby magazines and online, the majority of which prescribe “if you are having breastfeeding difficulties contact your health visitor”. Is it any wonder that the UK rate of breastfeeding drops dramatically after the first week as new mums follow the ignorant, often conflicting, advice of various health visitors?
It’s not only breastfeeding which is jeopardised, health visitors often dish out advice which is at odds with government guidelines on a range of topics, including weaning (The Guardian), sleep training (Naturally Nurturing), vaccinations (Redsell et al) and toilet training (Netmums).
Despite the power imbalance between mother and health visitor, there is much legal arsenal the mother can utilise to protect and withhold her rights. Firstly, a mother is not obliged to use the services of a health visitor and can refuse them at any time. A health visitor has no right of access to your home. Dingwall (Journal of Adv Nurs. Community nursing and civil liberty) has noted that “although health visitors have no legal right of entry, they do not make a habit of pointing this out to clients”. Health visitors have no legal power – it is social workers who have that.
Furthermore, there is no legal requirement to get your baby weighed. It is a service that is made available and advertised, but parents are not obliged to use it.
What if your health visitor has issued incorrect advice, breached confidentiality, undermined your confidence, acted discourteously or committed other misdemeanours? By making a formal complaint you can protect other families from such misconduct and improve the overall conduct of health visitors on a broader scale. You can make a complaint about your health visitor through several channels. Firstly, you should send a written or emailed complaint to your Primary Care Trust (to find your local PCT click here).
Secondly, you can send your complaint to the NHS’s Patient Advice and Liaison Services (Click here to find your local PALS).
If you need assistance with making your complaint The Independent Complaints Advocacy Service is a national service that supports people who wish to make a complaint about their NHS care or treatment (Click here to find your local ICAS).
If you’re not satisfied with the way the NHS deals with your complaint you can take your complaint to the independent Parliamentary and Health Service Ombudsman.
Another channel of complaint is the Nursing and Midwifery Council. This Council can investigate complaints from individuals who feel a health visitor, midwife or nurse has mistreated them. The Nursing and Midwifery Council has the power to remove or caution any practitioner who is found guilty of professional misconduct.
The address for the NMC is:
Nursing and Midwifery Council
23 Portland Place
London W1N 4JT
Tel: 020 7333 6541
You are also legally entitled to use The Data Protection Act to obtain any record that is compiled about you by the health visitor. First submit a written or emailed request to your health visitor’s Primary Care Trust (their employer). This is called a “Subject Access Request”. A small fee may be charged to process your request, usually around ten pounds sterling. You will need to send some documentation showing proof of your identity (photocopy of passport page) and proof of your residence (a utility bill). It should take about a month for the Trust to process your application.
If your request under the Data Protection Act is declined you may appeal the decision. To do this, send a written or emailed complaint to “The Head of Service” at the Primary Care Trust. Your appeal should be processed within one month.
As well as appealing internally you can also complain directly to the Information Commissioner. They are professionals appointed by the Crown to enforce information laws. The Information Commissioner can force the Primary Care Trust to disclose your data.
You also have the right to send The Primary Care Trust a notice within a reasonable time period asking them to stop processing your information. This is called a “data subject notice”. The notice must specify that the processing of personal information “is causing or likely to cause you or another person substantial, unwarranted damage or distress” and give reasons why.
Another legal right is the Right of Rectification. If you believe that the data recorded about you or your family was inaccurate, you can write to The Primary Care Trust and request the data be rectified. If you do not receive a satisfactory response from the Trust you can apply to the court for an order, or to the Information Commissioner for an enforcement notice, either of which may require that the inaccurate data, and any expression of opinion based on it, is rectified, blocked, erased or destroyed.
And finally, word of mouth is an excellent tool for disgruntled mothers. Discuss your experience with other parents and you may find that they have similar concerns. There is strength in numbers. Plus of course, you may ask for a different health visitor.
I wrote this article for the lovely ladies over at Free Your Parenting.