Understanding preventive community health services for pre-school children: origins, policy and current practice.
PhD, Bristol University.
Community health services for pre-school children have been the major universal health provision for well-children for over a hundred years. Traditionally these services have been largely delivered by health visitors, who are now community nurses with a specialist post-graduate qualification. Preventive health services for children in the UK have been increasingly criticised as insufficiently evidence-based. Criticism has led to reform of national policy and subsequent major changes to existing services, particularly in targeting services to those with the highest health and social needs. The effect of these policy changes upon the service provided for pre-school children by health visitors is not known. This thesis explores the origins and development of children’s preventive health services and examines the effect of post-1989 policy changes in practice, in particular the move to a predominately targeted child health promotion programme. The empirical study used a mixed methods approach to investigate changes to local policy and practice. A national survey was made of health visitors’ child health promotion practice (n=1043) which was followed by an in-depth interview study (n=25) of health visitors’ views on service changes. Study findings illuminate the effect of post-1989 reforms on child health services, showing a diversity of practice across the country, and resistance to key aspects of policy and practice among health visitors. Despite a revised national child health promotion programme being published in April 2008, which addresses some of the areas of concern highlighted by this study, flaws remain which have implications for the successful implementation of this programme. These flaws reflect wider contentious issues in NHS policy-making, related to the distribution of power and resources between different professional groups within the NHS and service users. Failing to explore these issues in policy and practice reduces the ability of preventive health services to maintain and improve pre-school children’s health.
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