Health visiting in the UK has its origins in the nineteenth century. Early health visitors started to be employed in Salford, Manchester from 1862. By 1905 health visitors were employed in about 50 towns. Their role was to visit families to advise them on nutrition and hygiene as there were very high levels of infant and maternal mortality. From the 1890s Florence Nightingale became interested in the potential for the role of health visitor in the community, as distinct from that of the nurse whose care was focused on sick people rather than preventative health. She was responsible for the profession’s first education programme.
In 1916 the profession of health visiting was established with the then, Royal Sanitary Institute, overseeing its education. Its’ first statutory qualification was established by the Ministry of Health in 2019, with the training divided equally between theoretical and practical training as it is to this day. Then it included:
Methods of artisan cookery and household management
Hygiene, infections and communicable diseases
Maternity and infant child welfare
Elementary economics and social problems
From 1925 a midwifery qualification became a requirement for all health visitors entering their training. It was only after 1945 that a previous nursing qualification became a pre-requisite alongside at least three months of midwifery. Both nurses and midwives can enter health visiting training today and the specific midwifery requirement has been dropped.
The role and training of the health visitor has evolved since then, responding to current public health challenges. The burden of disease tackled by the profession has moved over time, from infectious diseases and malnutrition that were worsened by poor hygiene and cramped housing in the nineteenth and early twentieth centuries, to tackling the antecedents of chronic diseases now. This includes a particular focus on promoting mental health, as well as ensuring children are ‘school ready’. Throughout, the role of the health visitor has primarily been to identify risk, to assess need, to promote health and to prevent ill health – working at the level of the infant, family and community. Some elements of the health visiting role such as developmental reviews and feeding follow ups, are increasingly delegated to members of a wider health visiting skill mix team of community nursery nurses and staff nurses.
Health visiting became a universal statutory service in 1929 with health visitors employed by local authorities until 1974 when their employment moved to the National Health Service (NHS). In 2015 the commissioning of health visiting services moved back to local authority public health departments in England but the majority of health visitors are still employed by the NHS. With devolution significant variation has entered the service and employment models across the UK. Whilst substantial income has been taken out of the service in England with the loss of a third of the workforce there has been new investment elsewhere with Scotland introducing a particularly exciting model of enhanced health visiting
When I entered health visiting in 1981, my role was to address health promotion in the community from ‘cradle to grave.’ I focused my time both on the most vulnerable in society, largely the very old and vulnerable children, and also universally on mothers and infants up to the age of five. I taught health promotion in schools and ran parentcraft classes alongside the local midwifery service. I also visited elderly people who had not had recent contact with health services. Today the focus of health visiting in the UK, is just on pre-school families and it increasingly encompasses the health needs of the father as well as of the mother and infants. Much of the wider group educational elements of the role have been lost, to focus directly on individual children and families. When the child enters school their care is passed to the school nursing service. School nurses now share a core training with health visitors before specializing in the health needs of the school age population.
All health visitors and school nurses working in the UK must adhere to the same set of standards which are overseen by their regulatory body, the Nursing and Midwifery Council. The latest,, and new standards can be seen here. The education curriculum is developed from these with the potential for some local variation to meet specific community needs. Health visitors and school nurses graduate with a first or Master’s degree but increasingly at Masters level. Some health visitors will then develop specialisms for working with specific groups such as the homeless, gypsies, travellers, refugees and prisoners, who are also parents of young children. Many areas also now employ health visitors as specialists in infant and perinatal mental health.
The focus of both health visitors and school nurses work in the UK remains holistic health promotion considering the physical, emotional and social needs of the baby and its family, or the school child, to ensure they have the best chance of enjoying a long and productive life and to reduce health inequalities. The universal service is focused on the early identification of risk and variation through regular touch points for developmental reviews. In England these are antenatally at thirty-six weeks and postnatally at two weeks, six weeks, one year and age two. There are significantly more universal contacts across the rest of the UK, with eleven in Scotland. We now understand the impact of family issues such as emotional wellbeing, substance abuse and domestic violence on the growing infant, so health visitors prioritise their remaining time for those families with these and other safeguarding issues.
Also prioritised, are those families with a child with developmental delays, special needs, young parents and those living in difficult circumstances.
More detail of the current health visitor services in the UK can be found on these infographics produced by the Institute of Health Visiting:
See also these recent films:
The Institute (www.ihv.org) was launched in 2012 as a Centre of Academic Excellence for the profession. Many of its’ resources will be of value to those working in similar roles across the world.
Dr Cheryll Adams CBE
Chair GNPHN and Founder, Institute of Health Visiting