What do health visitorscontribute to the care of

Original papers
What do health visitors contribute to the care of
children? A study in the north of England
In May 1985, an eight-page questionnaire was sent to all health
visitors in the Northern region of England. Three weeks later,
another questionnaire was sent to those who had not replied.
A second reminder was sent after a further three weeks, with
a few 'key' questions highlighted for health visitors not wishing
to fill in the whole questionnaire. During the same period, a
SUMMARY All the health visitors in the north of England,
and more than half the general practitioners, were sent questionnaires about the primary health care of children. More
than 90% of the health visitors responded. Most of them
took part in developmental screening and considered it
primarily their responsibility; some conducted developmental or well baby clinics with no other professionals present.
Clinics run by health authorities often occupied several hours
per week, and were more frequently attended by health
visitors than clinics run by general practitioners. Almost all
the health visitors' remaining time was spent in attached
practices, despite the fact that more than half said they had
neither office nor clinic space of their own on practice
premises. A high proportion of time was spent on clerical
work; more help with this could free the health visitor to
provide better developmental care for all children.
THE government's green paper on primary health care'
stated that 'Primary health care is best provided when family
doctors, community nurses and practice nurses work together
as members of a primary health care team'. The simultaneous
report on neighbourhood nursing,2 while agreeing in principle,
found that such teams do not work well unless all members
understand and respect the roles of other members, and noted
that full use is not always made of all the health visitor's skills.
To this end, a report by the Royal College of General Practitioners,3 and a handbook published jointly with the British
Medical Association,4 both make suggestions for improving
teamwork, including regular meetings between team members,
and good facilities and records.
Although the importance of health visitors in developmental
screening is frequently acknowledged, there has been little
research into how they view their work and responsibilities. The
present study undertook simultaneous surveys of health visitors
and general practitioners in the north of England. This paper
describes health visitors' perceptions of their role in the provision of paediatric developmental care within general practices,
and their work outside these practices. An earlier paper5
reported on the survey of general practitioners and on some comparisons between the two surveys.
G.N. Marsh, MD, FRCGP, general practitioner, Stockton-on-Tees; D.
Russell, MA, FSS, research assistant, Norton Medical Centre, Stocktonon-Tees; I.T. Russell, MA, MSc, PhD, FSS, director, Health Services Research
Unit, University of Aberdeen.
© Journal of the Royal College of General Practitioners, 1989, 39,
Journal of the Royal College of General Practitioners, May 1989
complementary questionnaire was sent to a sample of general
practitioners in the region, including at least one from each
The lists originally supplied by health authorities contained
697 health visitors known to work with children. By the completion of the survey, however, this had been reduced to 663 by
the loss of 34 health visitors who had left, retired or taken maternity leave. Five hundred and ninety nine (907o) completed questionnaires and 13 (20o) partly completed questionnaires were
Each questionnaire contained four sections, of which most
respondents needed to fill in only two. The first section asked
for the health visitor's qualifications, opinions on developmental screening, time spent on different types of work, and attendance at health authority clinics. The next two sections were addressed to health visitors attached to practices; the first of these
related to the practice with which they spent most time, and the
second to the practice with which they spent next to most time.
The final section was addressed to unattached health visitors.
Questionnaires were analysed on the Newcastle University
mainframe computer by the statistical package SPSSX.6 Health
visitors and their activities were analysed rather than practices.
Thus for the 142 health visitors who worked with two or more
practices, it was often necessary to derive a single answer from
separate answers to the two practice-specific sections. For the
number of hours worked, home visits or referrals, the sum of
the two practice-specific answers was used; for the number of
years spent in the practice, the average of the two practice-specific
answers was used; and a practice clinic was considered as
'available' if it existed in at least one of the two practices.
The denominator for percentages was taken as the number
of responses to the given question. As the distributions of the
numbers of hours worked, home visits and referrals were all
skewed, medians are used to describe the typical health visitor;
means are used to summarize the number of hours worked, since
they give useful extra information. Statistical significance was
tested by the chi-squared test; where appropriate, the variant
known as McNemar's test was used.7
Numbers and qualifications
Five hundred and seventeen (84Wo) of the respondents were fulltime and 95 (16%) part-time. After correcting for non-response,
it was estimated that there were 608 whole time equivalent health
visitors in the region working with children. As the estimated
population of the region was just over three million, including
1450 whole time equivalent general practitioners, there was one
health visitor for about 5000 people, or for 2.4 general
Of the 612 respondents, 127 (21%) qualified as health visitors
before 1970, 248 (41%o) qualified between 1970 and 1979, and
Original papers
G.N. Marsh, D. Russell and I.T. Russell
224 (37%/) qualified in 1980 or later. Five hundred and seventeen (84%) had at least one additional qualification (Table 1).
Responsibility and role
An earlier paper' contrasted the opinions of general practitioners and health visitors on who should be primarily responsible for developmental screening. The most common response
from both was an equal partnership of general practitioner and
health visitor. However, health visitors were more likely than
practitioners to assign primary responsibility to the health visitor,
alone or in partnership with a clinical medical officer; very few
assigned responsibility only to a general practitioner.
Table 2 contrasts the health visitors' present and ideal roles
in developmental screening. Almost all were conducting hearing tests and weighing, and organizing clinics, although some
thought that the last two should not be their responsibility.
However, the main discrepancy between the present and ideal
roles was in vision tests; nearly a quarter of all health visitors
would have liked to do these but did not.
Work of the health visitor
Most respondents (446, 74%0) were attached to only one practice, but 122 (200/) were attached to two practices, and 20 (30/)
to three or four practices; however, the latter were asked for
details of only two. The remaining 14 (20/o) were not attached
and worked only on a geographical 'patch' Of those attached
to practices who responded to the question, 566 (980/o) said that
their work within the practice included work with children under
12 years old, 499 (87%) said it included antenatal care, and 487
(8507o) said it included preventive work with adults.
Health visitors were asked to estimate how many hours per
week they spent on different types of work, both as part of their
Table 1. Qualifications of respondents.
State certified midwife
Fieldwork teacher
Family planning certificate
District nurse training
City and Guilds further education certificate
Registered state children's nurse
Obstetric course
Health education certificate
practice attachment and otherwise. Table 3 presents the corresponding means and medians, after exclusion of inconsistent
responses. Almost all (87%) full-time health visitors worked 37
or 38 hours per week; most of the rest worked about 40 hours.
Forty two per cent of part-time health visitors worked half-time;
the rest were evenly spread between 15 and 32 hours per week.
Although health authority clinics provided the majority of unattached work, 63% of full-time and 39% of part-time health
visitors did other unattached work.
Table 4 summarizes the number of home visits and referrals
health visitors made in the week preceding their response It also
Table 3. The working day of the health visitor.
Number of hours worked by:
Full-time health Part-time health
visitors (n=472) visitors (n=82)
Total work in practices
Other work
Work on a geographical
Health authority clinics
Hospital liaison
School health service
198 (33)
Excludes 175 full-time and 35 part-time health visitors whose responses
for different types of work within the practice(s) were missing or inconsistent. b Mainly by 14 unattached health visitors, although 13 attached health
visitors also spent part of their time working on a 'patch'.
Table 4. Home visits and referrals by health visitors in last five working days.
number for
number 663 health
number per
by all
visitors in
respondents northern
(n <585)
Table 2. Health visitors' present role and perception of ideal role
in child surveillance.
Testing hearing
584 (97)
568 (94)
Organizing clinics
557 (93)
Testing vision
349 (58)
Carrying out all developmental screening
168 (28)
a Key question. NS = not significant.
NB: 41 other qualifications were mentioned 154 times by 145 health visitors.
Number (%) of health
level of
(n = 602) (n <602)
Work with attached practices
Work with children under
12 years8
Antenatal carea
Work with adultsa
Other, including clerical
and meetingsa
Total work per week
Number (%)
of health visitors
(n = 612)
314 (51)
138 (23)
114 (19)
71 (12)
33 (5)
29 (5)
29 (5)
25 (4)
Child health surveillance visits
First postnatal
Other routine
Non-routine or requested
Other visits (including
Total visits
Referrals to:
Doctor in practice
School health service
Other professional
Total referrals
Journal of the Royal College of General Practitioners, May 1989
Original papers
G.N. Marsh, D. Russell and I.T. Russell
estimates totals for the region, after correcting for nonrespondents. All distributions were skewed with a few large
responses; for example, 18 health visitors made more than 60
visits, and 15 more than 14 referrals.
Attendance at clinics
Details of health authority and practice clinics attended by each
health visitor are given in Table 5. With the exception of antenatal
and postnatal clinics, more health visitors attended health
authority clinics than the corresponding practice clinics. Health
authority doctors and general practitioners were usually present
at health authority and practice clinics respectively; in addition
87 (16% of 533) health visitors were accompanied by a practice
doctor at at least one health authority clinic, and 82 (18% of
455) were accompanied by a health authority doctor at at least
one practice clinic. The only other profession attending frequently were midwives, typically at antenatal, postnatal and mothercraft clinics. In more than 10% of the developmental clinics they
attended (except six-week clinics), health visitors were not accompanied by other professions.
The health visitor within the practice
Our survey of general practitioners5 showed that virtually all
practices (97%) had at least one attached health visitor. Of the
health visitors attached to only one practice, 114 (26%) were
alone, 189 (441o) had one health visitor colleague, and 132 (301o)
had two or more health visitor colleagues. Of the health visitors
attached to two or more practices, 39 (297o) were alone in both
practices, 57 (43%) shared both practices with at least one other
health visitor and 38 (281o) were the only health visitors in one
practice but not both. Of the health visitors with at least one
Table 5. Health visitors' attendance at paediatric and related clinics.
Number (%) of
Number (%) of
health visitors attenhealth visitors
ding health authority attending practice
(n= 599)
(n= 599)
screening clinics
6 weeks
6-8 months
1-1.5 years
2-3 years
At least one
Other clinics
Well baby
Alone or
with other
HVs only
Alone or
with other
HVs onlya
393 (66)
309 (52)
281 (47)
316 (53)
230 (38)
8 (1)
93 (16)
39 (7)
28 (5)
37 (6)
231 (39)
191 (32)
164 (27)
182 (30)
133 (22)
7 (1)
66 (11)
31 (5)
29 (5)
27 (5)
108 (18) 288 (48)
75 (13)
437 (73)
482 (80) 47 (8)
297 (50)
3 (1)
237 (40)
11 (2)
Antenatal or
101 (17)
5 (1)
Family planning
37 (6)
3 (1)
At least one clinic 533 (89) 147 (25)
294 (49)
293 (49)
89 (15)
64 (11)
10 (2)
4 (1)
262 (44)
17 (3)
0 (0)
0 (0)
105 (18)
Health visitors attached to two or more practices are included in these
numbers if they attend the relevant clinic in either of the two practices for
which they gave details.
Journal of the Royal CoHlege of General Practitioners, May 1989
colleague, 231 (56%) worked with all patients in the practice,
143 (34%) with all patients in an area, and 41 (100o) with a
subgroup of patients not defined geographically.
TWo hundred and sixty nine (47%) health visitors had been
in their present practice(s) for three years or less, 137 (24%) for
between four and six years and 171 (30%) for seven or more
years. Table 6 presents health visitors' reports of facilities and
communications within practices. Our earlier paper5 compared
these with the general practitioners' reports: practitioners were
more likely than health visitors to say that facilities were available
and that discussions took place.
Unattached health visitors
The fourteen respondents who had no practice attachment worked with patients from between three and 20 practices. Six other
health visitors completed the questionnaire sections relating to
both a specific practice and a specific geographical 'patch'; seven
more said they did some work on a 'patch' The number of hours
the 14 unattached health visitors spent on work with children
under 12 years old, antenatal care, work with adults and clerical
work were similar to those given for attached health visitors in
Table 3. However, they referred fewer patients to general practitioners, and did fewer first postnatal and other routine visits.
Nine of them discussed patients 'only occasionally' with their
general practitioners; the other five discussed patients regularly with some, but not all, the relevant practitioners.
Finally, one hundred and eighty five health visitors (31Gb) added comments ranging from one sentence to three pages in length.
The most common topics were difficulties in liaising with general
practitioners (56), general practitioners' lack of understanding
of the health visitor's role (27) and the questionnaire (24).,
However, 35 made favourable comments about the practice or
its doctors.
The responding sample
More than 90% of health visitors responded, many with careful
and helpful comments. Lack of previous research probably contributed to this excellent response rate; unlike general practitioners, health visitors are not inundated with questionnaires
and other unsolicited mail. The structure of the profession may
also have improved the response; directors of nursing services
and nursing officers were very helpful, some even distributing
questionnaires and monitoring the response.
A relatively large proportion of health visitors (5% compared
with 1% of the similarly managed general practitioner sample5)
had left, retired or taken maternity leave between the compilation of the sampling frame and the return of questionnaires.
Furthermore, a high proportion of respondents (37%) had
qualified since the beginning of 1980 and even more (47%) had
spent less than four years in their present practice. We are concerned that frequent changes of health visitor, coupled with their
relative inexperience, may have a deleterious effect on relationships and thus on the effectiveness of child care within the practice. Indeed, several respondents commented that educating the
general practitioner about the proper role of the health visitor
was a long term process.
The profession remains overwhelmingly female; will 'equal
opportunities' policies change this in the future? Half our
respondents had a midwifery qualification, one fifth a family
Original papers
G.N. Marsh, D. Russell and I.T. Russell
Table 6. Facilities and communication within practices.
Number 1%) of health visitors
Attached to
one practice
only (n <436)
Office on practice premises
Office for HVs only
Clinic area for HVs only
Preventive care card for all children under 5 years
Formal policy discussions
Informal policy discussions
Frequency of discussions with GPs about patients:
At least weekly (in both practices)
Weekly to monthly (in both practices)
Less than monthly (in at least one practice)
One practice
28 (20)
14 (10)
8 (6)
114 (84)
27 (20)
26 (19)
23 (17)
11 (8)
82 (60)
97 (71)
104 (77)
11 (8)
96 (22)
326 (75)
3 (2)
69 (51)
24 (18)
28 (21)
110 (80)
38 (28)
328 (75)
86 (20)
22 (5)
planning certificate, and one fifth were fieldwork teachers.
Although many other qualifications were reported, additional
paediatric training was not prominent.
The work of the health visitor
Almost all respondents worked with children (the picture may
have been different among the few non-respondents), typically
devoting more than half the working week to their care. The
region was firmly committed to the primary health care team;
very few health visitors were not attached to practices. Although
it was thus rare for health visitors to wbrk unattached on'a
geographical 'patch' an analogous geographical zoning system
was common among practices'with at least two attached health
Home visits formed a major part of health visitors' work; their
median of more than five paediatric visits per day was considerably more than that of their practitioner colleagues.8
However, health visitors made few referrals; although this could
indicate poor liaison, it is more likely that the health visitor felt
capable of solving most problems without assistanc'e Regardless
of whether their own practices held clinics, most health visitors
spent several hours per week at health authority clinics. At present these perform a major role in developmeptal screening,;but
may decline in importance if practice provision improves.
Although a ratio of one health visitor to every 2.4 general practitioners may appear adequate for this work, this figure conceals wide variations between practices. There is scope fpr further research into the optimum provision of hei1th visitors,
especially if they are to take on preventive work with adVIlts and
work with the increasing elderly population. We judge that the
four hours per week they currently spend on these two activities
could be profitably increased.
The independent professional
More than two thirds of health visitors- thought the primary
health care team was the proper place for developmental screening,5 and more than half of these considered that practitioners
and health visitors should be equally responsible for it. Many
health visitors were running developmental clinics without a doctor present. More than one third wanted to do all developmental screening; this could well become the norm in future, with
a doctor available for exceptional cases.
Many health visitors felt undervalued by many of the general
Attached to two or more practices (n <137)
51 (37)
51 (37)
32 (26)
practitioners they worked with. Although relationships between
the two professions were generally good, health visitors' perceptions of these relation'ships were significantly worse than those
of practitioners.5 Nevertheless, they were content to work
within the practice team,-provided that their status as independent professionals, rather than practice employees, was
The health visitor within the practice
The health visitor's contribution to the practice team is hindered
by poor facilities and organization. The recommendations'of
the Royal College of General Practitioners4 to improve teamwork go largely unheeded, despite the need perceived by health
visitors. Only a minority had an office of their own on practice
premises; several commented that having these facilities would
improve communication. Even fewer had a clinic area of their
own. The virtual termination of the health centre programme
some years ago, and the resulting reliance on the expansion of
practice-owned premises, has deprived health visitors of the
facilities they need. If practices do not provide these facilities,
health visitors will increasingly look to clinical medical officers
as their colleagues in developmental care. More than a quarter
of them already favour this.
Few health visitors attended formal meetings to discuss practice policy, although many would have liked to do so. However,
most had frequent informal discussions about policy and patients. Health visitors attached to only one practice were more
likely to enjoy good facilities and communications than those
attached to two or more practices.
The typical health visitor spends nine hours each week on
clerical work and meetings. If more equipment, notably dictaphones, and clerical staff were available, the health visitor
would have more time to spend on the work for which she was
trained - improving developmental care through clinics and
home visits.
1. Secretaries of State for Social Services, Wales, Northern Ireland and
Scotland. Primary health care. an agendafor discussion (Cmnd 9771).
London: HMSO, 1986.
2. Department of Health and Social Security. Neighbourhood nursing
- a focus for care. Report of the community nursing review.
London: HMSO, 1986.
Journal of the Royal Coilege of Genenl Practitioners, May 1989
Original papers
G.N. Marsh, D. Russell and I.T. Russell
3. Royal College of General Practitioners. Healthier children thinking prevention. Report from general practice 22. London:
RCGP, 1982.
4. General Medical Services Committee and Royal College of
General Practitioners. Handbook of preventive care for
preschool children. (2nd edn). London: British Medical
Association and RCGP, 1988.
5. Marsh GN, Russell D, Russell IT. Is paediatrics safe in general
practitioners' hands? A study in the north of England. J R Coll
Gen Pract 1989; 39: 138-141.
6. SPSS Inc. SPSSX user's guide. New York: McGraw-Hill, 1983.
7. Armitage P. Statistical methods in medical research. Oxford:
Blackwell, 1971.
8. Whewell J, Marsh GN, McNay RA. Changing pattern of home
visiting in the North of England. Br Med J 1983; 286:
We thank the Department of Health and Social Security for financial
support, the research committee of the north of England faculty of the
Royal College of General Practitioners (in particular Dr Colin Waine)
for advice, the health visitors for completing their questionnaires and
Kathleen Macfarlane and Peta White for secretarial support.
Address for correspondence
Dr G.N. Marsh, Norton Medical Centre, Harland House, Norton,
Stockton-on-Tees, Cleveland TS20 IAN.
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