The State of Health Visiting in England: Workforce Composition, Caseloads and Service Delivery

Utilizing new Freedom of Information data from 147 English Local Authorities, this study reveals that while health visiting spending remains progressive and mandated contact completion is stable across deprivation levels, the workforce has contracted and shifted toward lower-skilled staff with rising caseload pressures that disproportionately affect the most deprived areas, necessitating approximately 3,100 additional staff and £120 million annually to restore recommended service levels.

The Gist

Imagine England's health visiting service as a giant, nationwide safety net designed to catch every family with a baby or young child. Its job is to check on the kids, teach parents how to stay healthy, and spot any problems early before they become big, expensive crises later in life.

This report, written by a team of researchers, takes a hard look at this safety net between 2016 and 2021. They found that the net has been getting smaller, fraying at the edges, and stretched to the breaking point.

Here is the story of what happened, explained simply:

1. The "Master Craftsmen" Are Leaving the Workshop

The safety net is woven by two types of people:

• Health Visitors (HVs): These are the Master Craftsmen. They are highly trained nurses or midwives with special degrees. They are the ones legally required to lead the checks and make the big decisions.
• Clinical Skill Mix Staff (CSMS): These are the Apprentices and Assistants. They are helpful, trained workers (like nursery nurses) who can do many tasks, but they don't have the same specialized training as the Masters.

What happened?
Between 2016 and 2021, the number of Master Craftsmen dropped by 21%. It's like a bakery losing a fifth of its master bakers. To keep the ovens running, the bakeries hired more Apprentices (who increased by 33%).

While having more assistants sounds good, you can't just replace a master baker with an apprentice for every single cake. The report warns that while the total number of workers didn't drop as much, the quality of the team changed. They are trying to do the same amount of work with fewer experts and more helpers.

2. The "Too Many Customers" Problem

Imagine a single Health Visitor is a barber. The government says a barber should only have 250 customers on their chair list to do a good job.

The Reality:
By 2021, the average Health Visitor in England was trying to manage 350 to 400 customers, and in some towns, they were juggling over 1,000.

• The Analogy: It's like asking one barber to cut hair for a whole football stadium. They are running so fast they can't stop to talk to the customers, check their scalp, or notice if the customer looks sad. They are just "ticking boxes" to get through the line.

3. The Great "Panic Move" (COVID-19)

When the pandemic hit in 2020, the government told all these barbers to stop cutting hair and go help in the hospital emergency room instead.

• The First Wave: Almost 70% of local areas sent their health visitors away to fight the virus. For months, the safety net was left empty. Families who needed help didn't get their regular check-ups.
• The Second Wave: They were called back a bit, but the damage was done. The "barbers" were exhausted, and many had already left the job.

4. The Money Drought

Who pays for the barbers? The local town councils (Local Authorities).

• The Trend: Between 2016 and 2025, the money given to these councils for this specific job shrunk by nearly 20% (when you adjust for inflation).
• The Result: It's like a family being told to feed a family of five with the grocery budget for three people. They have to cut corners, buy cheaper ingredients (less experienced staff), and serve smaller portions (fewer visits).

5. Does it matter if you live in a rich or poor town?

The researchers looked at whether the poorest towns got hit harder.

• The Good News: The poorest towns actually spend more money per child than the rich towns. They know they need more help.
• The Bad News: The money cuts hit everyone equally. It's like a drought that dries up the water for the rich mansion and the small cottage at the same time. Even though the poor towns try to spend more, they are still running out of water because the main pipe (national funding) is being turned down.

6. The Cost to Fix It

The report asks: "How much would it cost to fix this mess?"

• To get the "barbers" back to a safe number (250 customers each), England needs to hire about 3,100 new Health Visitors.
• The Price Tag: This would cost about £120 million a year in wages.
• The Perspective: The government has recently promised billions for new "Family Hubs" and early years programs. The researchers say: "You can't build a new house if you don't hire the builders." If they don't fix the workforce first, all the new money for new programs will just sit on the shelf because there are no people to deliver them.

The Bottom Line

The safety net for England's babies is currently stretched so thin it might snap.

• There are fewer experts.
• The remaining experts are overwhelmed.
• The funding is shrinking.
• The pandemic made it worse.

The Solution: The government needs to stop treating this service as a "nice-to-have" and start treating it as essential infrastructure. They need to hire more experts, pay for their training, and give them a manageable workload. Otherwise, the promise of a "healthy start in life" for children will remain just a slogan, not a reality.

Technical Summary

1. Problem Statement

The paper addresses a critical gap in the understanding of England's health visiting workforce following the 2015 devolution of commissioning responsibilities from the NHS to Local Authorities (LAs). Prior to this study, data on health visiting was fragmented:

• NHS Digital statistics only captured Health Visitors (HVs) employed by NHS Trusts, excluding Clinical Skill Mix Staff (CSMS), student HVs, and staff employed by independent providers or councils.
• The Community Services Dataset (CSDS) suffered from patchy coverage and was deemed unreliable for workforce planning.
• Consequences: This data fragmentation obscured the true scale of workforce contraction, the shift in skill mix, and the impact of austerity and the COVID-19 pandemic on service delivery. The authors argue that without robust data, the government's renewed policy focus on early intervention (e.g., the NHS 10-Year Health Plan) cannot be effectively implemented or evaluated.

2. Methodology

The authors employed a novel Freedom of Information (FOI) data collection strategy to construct a comprehensive, granular dataset of the health visiting workforce across England.

• Data Collection:
  • Scope: FOI requests were sent to 147 Upper Tier Local Authorities and service providers between October 2019 and December 2022.
  • Variables: The dataset captures Full-Time Equivalent (FTE) numbers disaggregated by:
    • Staff Type: Registered Health Visitors (HVs) vs. Clinical Skill Mix Staff (CSMS).
    • Pay Bands: Based on the NHS Agenda for Change (AfC) system (Bands 2–8).
    • Caseload Status: Staff holding direct caseloads vs. non-caseload staff.
    • Geography: Data is available at the Local Authority level.
  • Timeframe: Annual snapshots from 2016 to 2021 (specifically February 1st of each year).
  • Pandemic Extension: Specific data on staff redeployment was collected for the first and second waves of the COVID-19 pandemic (Sept 2020–March 2021).
• Sample Composition:
  • Complete Total FTE Sample: 75 LAs with complete data for all years (2016–2021).
  • Complete Caseload FTE Sample: 66 LAs with complete data on caseload-holding status.
  • Validity: The authors conducted statistical tests (Kolmogorov-Smirnov, t-tests) comparing included LAs against excluded LAs on deprivation indices, demographics, and health outcomes, finding no statistically significant differences, thus validating the sample's representativeness.
• Analytical Approach:
  • Trend Analysis: Longitudinal analysis of workforce composition and caseload sizes.
  • Inequality Analysis: Stratification by baseline deprivation using the Income Deprivation Affecting Children Index (IDACI) tertiles.
  • Cost Modeling: Estimation of the financial investment required to restore workforce capacity to recommended caseload levels (250 children per practitioner) under different staffing mix scenarios (100% HV, 50/50 mix, 100% CSMS).
  • Comparative Analysis: Benchmarked against data from Wales and Scotland (collected via FOI for Feb 2020).

3. Key Contributions

• First Granular National Dataset: This is the first study to provide a comprehensive, LA-level view of the entire health visiting workforce (including CSMS and non-NHS providers) in England.
• Quantification of Skill-Mix Shift: It documents the structural transformation of the service from a HV-led model to one increasingly reliant on lower-banded CSMS.
• Caseload Crisis Documentation: It provides empirical evidence that average caseloads have far exceeded the Institute of Health Visiting (iHV) recommended threshold of 250 children per practitioner.
• Costed Policy Proposals: The paper moves beyond diagnosis to provide specific, costed estimates for rebuilding the workforce, linking these costs to existing government funding commitments (e.g., Best Start Family Hubs).
• Pandemic Impact Assessment: It quantifies the extent of service disruption caused by the redeployment of health visiting staff during the COVID-19 pandemic.

4. Key Results

A. Workforce Composition and Capacity (2016–2021)

• Decline in HVs: The number of FTE Health Visitors fell by 21% (from 5,631 to 4,472). The decline was most acute in Band 6 (the core qualified grade), dropping from 4,522 to 3,664.
• Rise in CSMS: Clinical Skill Mix Staff increased by 33% (from 2,002 to 2,664), concentrated in Bands 4 and 5.
• Net Contraction: Despite the rise in CSMS, the total workforce capacity contracted by 6.5%.
• Geographic Shift: Nearly 80% of Local Authorities experienced a decline in the share of HVs within their teams. In 2021, nearly one-third of LAs had fewer than 60% HVs in their workforce.

B. Caseload Pressures

• Exceeding Thresholds: Approximately 74% of Local Authorities exceeded the recommended caseload of 250 children per practitioner.
• Extreme Cases: Some LAs reported average caseloads exceeding 1,000 children per practitioner.
• CSMS Caseloads: In areas using a "corporate" (shared) caseload model, the percentage of CSMS holding caseloads was significantly higher (63.3%) compared to non-corporate models (41.5%).

C. Spending Trends

• Real-Term Cuts: Spending on mandated 0-5 services fell by nearly 20% in real terms between 2016-17 and 2024-25.
• Per-Child Spending: While total spending is higher in less deprived areas (due to larger populations), per-child spending is consistently higher in the most deprived areas. However, the trajectory of cuts has been similar across all deprivation groups, indicating system-wide austerity.

D. COVID-19 Redeployment

• First Wave: 68.7% of LAs redeployed at least one health visiting staff member. On average, 9.1% of HVs and 17.8% of CSMS were redeployed. In the most affected areas, up to 45% of HVs and 83% of CSMS were reassigned.
• Duration: Redeployments were sustained, with staff often remaining redeployed well past the official restoration of services in June 2020.
• Second Wave: Redeployment was significantly more limited (only ~17-18% of LAs redeployed staff).

E. Inequalities and Service Delivery

• Resource Distribution: More deprived areas generally employ more staff per child and spend more per child than less deprived areas, suggesting a progressive distribution of resources.
• Service Delivery: Completion rates for mandated contacts (e.g., New Birth Visits, 6-8 week reviews) showed relative stability across deprivation gradients, though the authors note this may mask differences in the quality or intensity of contacts.
• Workforce Trends in Deprived Areas: HV declines were slower in deprived areas, but CSMS growth was also weaker, suggesting a complex interaction between funding cuts and local needs.

F. Cost of Restoration

• To restore average caseloads to the recommended 250 children per practitioner (based on 2020 pre-pandemic data scaled to 2024 population):
  • Workforce Shortfall: Requires hiring approximately 3,100 additional FTE staff.
  • Annual Wage Cost: Estimated at £120 million per year (assuming a 50:50 HV/CSMS mix).
  • One-off Training Cost: Estimated at £81 million (for HV training).
• The authors argue this investment is feasible within the context of recent government commitments to early years initiatives (e.g., Best Start Family Hubs).

5. Significance and Policy Implications

• Structural Constraint: The current under-resourced workforce poses a structural barrier to the government's ambitions for prevention and early intervention (NHS 10-Year Health Plan, DfE Early Years Strategy). Without rebuilding capacity, these policies cannot achieve their intended impact.
• Inequality Risks: While per-child spending is progressive, the system-wide nature of cuts and rising caseloads threaten to erode the ability of services to address regional inequalities effectively.
• Data Infrastructure: The study highlights the urgent need for a unified national data system that captures all providers and staff groups to enable consistent monitoring and planning.
• Recommendations:
  1. Establish a unified national data system for the full health visiting workforce.
  2. Secure sustainable funding to restore safe caseload levels, prioritizing deprived areas.
  3. Align workforce restoration with the rollout of new early years initiatives (Best Start Family Hubs) to ensure maximum impact.

In conclusion, the paper provides irrefutable evidence that the health visiting service in England is in a state of crisis, characterized by a shrinking workforce, a shift toward lower-skilled staff, and unsustainable caseloads. It argues that immediate, targeted investment is required to reverse these trends and fulfill the statutory mandate of the Healthy Child Programme.