Intended for healthcare professionals

Letters Government’s misplaced prevention agenda

Health visitor numbers: silk purse or sow’s ear?

BMJ 2019; 364 doi: (Published 08 February 2019) Cite this as: BMJ 2019;364:l599
  1. Chris Tiley, general practitioner
  1. Lander Medical Practice, Truro TR1 2JA, UK
  1. chris.tiley{at}

Hiam and Dorling critique the government’s new prevention plan.1 My colleagues and I have become concerned about difficulties accessing the support of health visitors.

A request under the Freedom of Information Act shows that in 2012 there were 76 full time equivalent health visitors in Cornwall, which rose to a peak of 117 in 2015, then fell by 29% to 83 in 2018. This is in keeping with data from the Institute of Health Visitors showing a 20% cut in numbers from 2015, when responsibility moved from the NHS to local authorities.

The institute recommends a ratio of one health visitor to 250 children, or to 100 children in deprived areas (which are prevalent in Cornwall). Given a 2011 census population of 536 000 and a demographic estimate of 6.2% of the population being 0-4 years old, I estimate that there are at least 33 232 children in the health visitor target group. Applying the ratio from the institute gives a minimum number of 133 full time equivalent health visitors, without considering the additional effects of deprivation and population growth or that health visitors cover children up to age 5. This indicates a minimum shortfall of 50 health visitors; 38% of the number required for effective working, and probably nearer 50%.

The long term plan hints at the importance of prevention, and there is an overwhelming case for such an agenda with an estimated 80-90% of health being shaped by social determinants. But advocating for this approach while presiding over cuts to public health and crucial services like health visiting is misleading.

You cannot make a silk purse out of a sow’s ear. Expanding the health visitor programme would align perfectly with the government’s objectives, improving opportunities for all, but especially those who are most disadvantaged. For the future population to enjoy good health we all need a sure start.



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