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

Background Health visitors in the United Kingdom work mainly with pre-schoo l children and their mothers. Their distribution across the population is l argely historical, highly variable and relates poorly to indicators of popu lation need. Methods A range of largely routine data sources were used to describe the n ature, variation and statistical determinants of the workload of individual health visitors in Sheffield, England, in 1996-1997. Regression models wer e tested relating measures of need and deprivation to the total number of c lient contacts. Results Caseloads were smaller in the most deprived areas, with wide variat ion. Most (93 per cent) contacts were with mothers and young children. Heal th visitors visited the clients designated as highest priority on average 4 .7 times more often than routine clients. The main reasons for high priorit y ratings were child protection concerns, maternal mental health problems, child development and health concerns, and first-time mothers in the postna tal period. Half of all client contacts were with low-priority families for routine child health surveillance or were client initiated. Models based o n the number of children under five and any one of a range of measures of s ocial deprivation account for 57-59 per cent of variation in workload and c ould be used to allocate resources more equitably. Conclusions Although most health visitors apparently subscribe to the princ iple of targeting, the extent varies widely. Constraints on targeting are r outine child health surveillance reviews, and client demands. More equitabl e allocation of health visitors and more explicit targeting policies might increase the effectiveness of the health visiting service.