Hitting the target: the equitable distribution of health visitors across caseloads

Health visitors in the United Kingdom work mainly with pre-school children and their mothers. Their distribution across the population is largely historical, highly variable and relates poorly to indicators of population need.

A range of largely routine data sources were used to describe the nature, variation and statistical determinants of the workload of individual health visitors in Sheffield, England, in 1996-1997. Regression models were tested relating measures of need and deprivation to the total number of client contacts.

Caseloads were smaller in the most deprived areas, with wide variation. Most (93 per cent) contacts were with mothers and young children. Health visitors visited the clients designated as highest priority on average 4.7 times more often than routine clients. The main reasons for high priority ratings were child protection concerns, maternal mental health problems, child development and health concerns, and first-time mothers in the postnatal period. Half of all client contacts were with low-priority families for routine child health surveillance or were client initiated. Models based on the number of children under five and any one of a range of measures of social deprivation account for 57-59 per cent of variation in workload and could be used to allocate resources more equitably.

Although most health visitors apparently subscribe to the principle of targeting, the extent varies widely. Constraints on targeting are routine child health surveillance reviews, and client demands. More equitable allocation of health visitors and more explicit targeting policies might increase the effectiveness of the health visiting service.