Enhancing health visiting service in Scotland: a realist evaluation

Background: In the middle of 2013, NHS Ayrshire and Arran in Scotland transformed their health visiting service by increasing the number of home visits and a focus on pre-birth to 5 years. The service change was a pilot... [ view full abstract ]

Background:
In the middle of 2013, NHS Ayrshire and Arran in Scotland transformed their health visiting service by increasing the number of home visits and a focus on pre-birth to 5 years. The service change was a pilot programme set within the wider context of the recommendations of NHS Scotland Chief Executive Letter (CEL) 13 (2013), which aims to refocus health visiting in order to improve care delivery within the community and tackle health inequalities.
The primary aim of this evaluation was to understand how the enhanced health visiting service works, with a view to inform the impending implementation and evaluation a structured, increased home visiting service in Scotland.

Methods:
A realist evaluation design was considered to be the best approach to answer the evaluation questions. The evaluation was conducted in three phases: phase 1 defines the programme theory; phase 2 tests the programme theory; and phase 3 provides an explanation and refinement of the programme theory. In phase 1, eight managerial staff who were involved in developing and implementing the programme provided data, which were used to formulate programme theories. In phase 2, the theories were tested using qualitative data from 25 health visitors who delivered the service and 22 parents who received the service. In phase 3, all the data were brought together and explanation of how the programme works was provided.

Findings:
Facilitating mechanisms: Parents’ increasingly viewed health visitors as their first point of contact on wellbeing and developmental-related issues. This was primarily due to more trusting relationships they have developed with health visitors through the enhanced programme. They also felt comfortable contacting health visitors by phone for additional support. Although this was possible in the previous service, however, health visitors reported that the frequency of contacts had increased. Both parents and health visitors reported that the programme has improved early identification of concerns, leading to early engagement with wider services, including nursery services, in ways that were not previously possible. Also, health visitors felt that the changes have made their role much clearer and well defined. They perceived that this has enhanced their professional partnership working.
Constraining mechanisms: Both parents and health visitors found the gaps between some home assessment visits in the timeline too wide. Some health visitors, were concerned about referral pathways. They felt they were cumbersome and presented significant challenges to the enhanced service. Health visitors universally acknowledged that increased home visiting has been challenging and reported that they struggled to fulfil the entire timeline. This prompted some areas to involve staff nurses and skill mix staff to fulfil the timeline.

Conclusion:
Realist evaluation was instrumental in terms of identifying factors which may require further consideration to improve outcomes in the nation-wide roll-out of the enhance service.