High-impact areas for health visiting (ages 0 to 5)

Question 1

1. The transition to parenthood

Accepted Answer

Overview of high-impact area 1: ages 0 to 5

The transition to parenthood refers to the period from conception through to the early months of a child’s life - a time when individuals are adapting to new roles and responsibilities as parents. This life stage brings profound emotional, physical, psychological and social changes (see reference 1 in the Annex: references) that can influence parental mental health, bonding and attachment, and the long-term wellbeing of the child (as cited in the Parent-Infant Foundation’s Maternal attachment and child outcomes report).

While this transition can be a time of joy and growth, it can also present significant challenges. Supporting families during this period is critical to laying the foundations for lifelong health, development and emotional security. More broadly, supporting families throughout the early years is critical to giving every child the best start in life.

Why the transition to parenthood is important

There is compelling evidence that the 1,001 days from conception to the age of 2 set the foundations for our cognitive, emotional and physical development.

The Parent-Infant Foundation’s Securing Healthy Lives report states that the quality of early parenting and attachment is a major predictor of long-term outcomes in children, including physical and emotional health, school readiness and future relationships. Babies who develop secure attachment patterns with their parents and carers during infancy have improved developmental outcomes, and these attachments can act as a buffer to babies against the detrimental impacts of poverty and other environmental factors.

The first 1,001 days also marks a period of heightened parental motivation - when families are particularly receptive to support and guidance that can improve their baby’s life chances. This makes it a prime opportunity to promote positive behaviour change, helping parents adopt healthy routines, strengthen relationships and make informed choices that benefit their child’s development.

Supporting families during this transition can achieve the following. It can:

strengthen parental confidence and resilience
improve perinatal mental health
promote secure parent-infant attachment
reduce the risk and impact of adverse childhood experiences (ACEs)
reduce inequalities in child outcomes, according to the Institute of Fiscal Studies
enable early identification of risks, including domestic abuse, which is a known risk factor during pregnancy
encourage sustained behaviour change by building on parents’ natural motivation to do the best for their baby

This aligns with the government’s 10 Year Health Plan for England: fit for the future and Giving every child the best start in life strategy. Both emphasise the foundational importance of the 1,001 days, and the value of integrated, preventative support for families.

Health visitors play an important role in delivering this vision - particularly for underserved families facing social disadvantage, housing insecurity or health inequalities - by providing expert, relational-based care and acting as a bridge between services.

Handover from maternity to health visiting services

A clear, timely and clinically informed handover from maternity to health visiting services is essential to ensure continuity of care. The handover between the midwife and health visitor should include a full account of maternal health needs and conditions, including:

physical and mental health
labour and delivery outcomes (known risk factors)
any safeguarding concerns

The MBRRACE-UK Saving Lives, Improving Mothers’ Care 2021 to 2023 report found that fragmented care and poor communication between services are contributing factors in preventable maternal deaths.

The role of the health visitor in the transition to parenthood

Health visitors are qualified specialist community public health nurses (SCPHNs) and lead the delivery of the healthy child programme between ages 0 to 5. They play a critical role in improving outcomes during the transition to parenthood, such as:

supporting secure parent infant attachment
promoting parental physical, emotional and mental health, and wellbeing
facilitating optimal child development
reducing health inequalities

Their role is underpinned by public health principles such as prevention and early intervention, as well as inequality reduction.

Health visitors are uniquely placed to do the following:

build trusting relationships with families during pregnancy and the early postnatal period, offering continuity of care and a non-judgemental space for parents to explore challenges or concerns
lead holistic assessments that consider the physical, emotional and social context of family life, identifying both protective factors and emerging risks
champion infant mental health and early attachment, using their expertise to support sensitive, responsive parenting and promote secure parent-infant relationships
identify signs of physical health issues postnatally (particularly signs of cardiac concerns - a leading indirect cause of maternal deaths)
act as a bridge between services, working across health, social care and community sectors to ensure families receive co-ordinated, joined-up support
promote health equity, ensuring that services are accessible, inclusive and culturally sensitive - particularly for underserved or marginalised families
support system leadership, contributing to local early years strategies, integrated care systems (ICSs) and multi-agency planning to improve outcomes for families and children
deliver public health messaging on major issues such as perinatal mental health, breastfeeding, healthy weight, physical activity and home safety
prevent, identify and respond to safeguarding concerns (including domestic abuse, parental mental illness and substance misuse), ensuring timely referral, collaboration and intervention

Health visitor leadership in the early years system, and the high-quality support they provide to parents and children from pregnancy to age 5, is fundamental to improving child development and reducing inequalities. By working collaboratively across community services, health visitors:

strengthen the co-ordination of support for families
promote secure parent-infant relationships
help set a family on course for lifelong health and wellbeing

The 4 levels of service offered during the transition to parenthood

Community-level offer

At the community level, health visitors have a crucial part in shaping environments that support a positive transition to parenthood. They work in partnership with midwifery teams, local services, voluntary organisations and community leaders to create a culture where families feel well informed, supported and confident to seek help.

Health visitors have the following core responsibilities at community level. They:

collaborate with midwives, general practice services, maternity voices partnerships and Best Start Family Hubs to deliver consistent public health messaging on:
- mental health in pregnancy
- infant bonding and responsive parenting
- breastfeeding and infant feeding choices
- healthy lifestyles, including physical activity and nutrition
contribute to national and local campaigns, such as Maternal Mental Health Awareness Week and ICON: Babies cry, you can cope
promote early access to antenatal services, encouraging timely booking and engagement with maternity care, particularly among underserved groups
raise awareness of the importance of the critical 1,001 days, using community events, outreach and digital platforms to share accessible, culturally relevant information
build community capacity through actions such as the following:
- partnering with, for example, midwifery services, Best Start Family Hubs, libraries, faith groups and local charities to host antenatal and postnatal information sessions
- supporting peer-led groups and parent champions to share lived experience and reduce stigma around seeking help
- encouraging co-production of services with families to ensure they reflect local needs and diversity
advocate for inclusive, trauma-informed environments in community settings, ensuring services are welcoming and accessible to all families, including those with additional needs or language barriers
support local system leadership, contributing to early years strategies and integrated care planning to ensure the transition to parenthood is prioritised in local health and wellbeing agendas

This community-level work reflects the government’s strategic direction outlined in the 10 Year Health Plan - moving healthcare closer to where families live and shifting the focus from treating illness to preventing it. Health visitors contribute to this by:

fostering supportive environments
promoting early engagement with services
embedding preventative public health messages across the perinatal period

They ensure that no family is left behind during the critical early years - particularly at major transition points such as pregnancy, birth and the early postnatal period.

Universal-level offer

This universal offer ensures that every family receives high-quality, personalised support, while also enabling early identification of those who may benefit from targeted or specialist input. By discussing a wide range of physical, emotional and practical topics, health visitors help parents - mothers and fathers alike - navigate the transition to parenthood with confidence. This includes exploring expectations, family dynamics and birth experiences, with sensitivity to any trauma that may impact early bonding or wellbeing.

The offer reflects the government’s ambition to embed prevention from conception onwards, reduce inequalities, and ensure that every child has the opportunity to grow, play, learn and thrive. By identifying and addressing need, health visitors aid the government’s Break down barriers to opportunity mission by striving to ensure that an individual’s success in life is not limited by the luck of their circumstances at birth.

As part of the core universal offer, health visitors:

initiate contact during pregnancy, typically around 28 weeks’ gestation, through a home-based antenatal health and development review. This visit is a major opportunity to:
- conduct a holistic health needs assessment that explores physical, mental, emotional and social wellbeing
- build rapport and trust with both parents to maximise engagement
- identify protective factors and emerging risks that may affect the transition to parenthood
- ensure effective collaboration with midwifery services to support safe and joined-up pathways of care
use inclusive, culturally sensitive approaches, which may include the following:
- interpreters and translated materials
- resources that reflect local diversity and lived experience
- trauma-informed communication to support families with previous adverse experiences
- accessible information for individuals with low literacy levels or learning needs
provide anticipatory guidance on:
- infant care, feeding choices and safe sleep
- mental health and emotional wellbeing
- healthy lifestyles, including physical activity and nutrition during pregnancy
- the importance of early bonding and brain development
- responsive and sensitive parenting
promote breastfeeding and explore feeding intentions early, offering non-judgemental support and signposting to local infant feeding services
discuss Healthy Start eligibility and promote the use of vitamins and supplements, including folic acid and vitamin D
support parents to understand the importance of the critical 1,001 days, and how their behaviours and relationships shape their baby’s development
explore family dynamics, support networks and expectations of parenthood, helping parents prepare emotionally and practically for their new role
signpost to universal services and resources, including Start for Life materials, local antenatal education and parenting groups, Best Start Family Hubs, libraries and community-based support
reinforce major public health messages through every contact, including:
- smoking cessation
- alcohol and substance use in pregnancy
- oral health
- immunisations and screening
- home safety and accident prevention
- contraception and family planning

This universal offer ensures that every family receives high-quality, personalised support, while also enabling early identification of those who may benefit from targeted or specialist input.

Targeted-level offer

At the targeted level, health visitors provide additional, time-limited support to families who have increased vulnerability or emerging needs during the antenatal or early postnatal period. This support is tailored to address specific challenges that may affect the transition to parenthood, and the health and wellbeing of the infant.

At the targeted level, health visitors:

analyse information from the antenatal health needs assessment to co-produce a support plan with parents, focusing on areas such as:
- mild to moderate perinatal mental health difficulties
- anxiety, low mood or emotional distress
- social isolation, lack of support networks or relationship strain
- housing insecurity, financial stress or food poverty
deliver evidence-based interventions, including:
- additional visits to support emotional wellbeing
- the promotion of methods such as the Solihull Approach to promote reflective parenting and emotional containment
- parent-infant observations to strengthen bonding and attachment
promote healthy behaviours during pregnancy, including:
- nutrition and physical activity
- smoking cessation and substance misuse support
- breastfeeding preparation and infant feeding choices
- safe sleeping
provide additional home visits or clinic contacts to reinforce core messages and monitor progress
work in partnership with midwives, GPs and early years practitioners to ensure co-ordinated care and timely referrals
support young parents, care-experienced parents and those with limited English proficiency to access services and build parenting confidence. This includes:
- during the new birth visit, exploring the birth experience with sensitivity, recognising that a difficult or traumatic birth may affect parental wellbeing, bonding and confidence, and offering additional support or referrals as needed
- supporting informed choices around contraception and family planning, ensuring parents understand their options and can access services - this is particularly important for those at risk of rapid repeat pregnancies
- supporting access to targeted services, such as parenting programmes, peer support groups, housing and welfare advice, and local mental health and wellbeing services
- monitoring for escalating needs or safeguarding concerns, ensuring appropriate transition to specialist pathways if required

This targeted offer reflects the principle of proportionate universalism, ensuring that families with greater needs receive more intensive support. It aligns with the 10 Year Health Plan’s commitment to early intervention, neighbourhood-based care and reducing inequalities in the critical 1,001 days.

Support at this level is typically time limited, proportionate to need and may be delivered by the most appropriate member of the health visiting team.

Specialist-level offer

At the specialist level, health visitors support families where the transition to parenthood is significantly impacted by complex, long-term or high-risk needs. These may include:

severe perinatal mental illness
safeguarding concerns
domestic abuse
substance misuse
where a child has a diagnosed disability, chronic condition or complex developmental need

This specialist offer ensures that families facing the most complex challenges during the transition to parenthood receive intensive, co-ordinated and compassionate support. The offer aligns with the 10 Year Health Plan vision by:

embedding multi-agency working and safeguarding within early years care to protect and support vulnerable families
reducing long-term inequalities through relationship-based, trauma-informed practice that strengthens resilience and parental capacity
facilitating access to culturally competent and flexible services, which reduces barriers for families with language needs, disabilities or complex social circumstances

At the specialist level, health visitors:

identify specialist needs through antenatal and postnatal assessments, professional judgement, and collaborative conversations with parents and other professionals
support parents through complex transitions, including:
- adjusting to parenthood while managing severe mental health conditions
- navigating the emotional and practical challenges of parenting a child with special educational needs and disabilities (SEND), life-limiting or chronic illness
- coping with trauma, abuse or unstable living environments during the perinatal period
- processing difficult or traumatic birth experiences that may affect recovery, bonding or mental health
provide trauma-informed care, recognising how past or current experiences may impact the parent-infant relationship and the ability to engage with services
support both parents - including fathers and non-birthing partners - to adjust to their new roles, access services and feel included in care planning
refer to and work alongside specialist services, including:
- perinatal mental health teams for complex or enduring mental health needs
- Family Nurse Partnership for eligible young or first-time parents
- safeguarding teams where there are concerns about abuse, neglect or exploitation
- domestic abuse and substance misuse services
- supporting early identification and sustained intervention for children with SEND or chronic health conditions, beginning in the perinatal period, and liaising with services and paediatric care for children with additional needs.
- social care and early help teams for families requiring statutory or intensive support
- genomic counsellors when a life-limiting or life-changing condition is diagnosed in pregnancy or the postnatal period that may impact on decisions about future pregnancies
contribute to multi-agency planning and reviews, including:
- child protection and child in need plans
- early help assessments
- team around the family (TAF) meetings
provide additional health visiting input as part of a multidisciplinary team, including:
- joint visits with specialist practitioners
- ongoing developmental monitoring and health promotion
- advocacy for the child’s and family’s needs within safeguarding and care planning
ensure continuity and co-ordination of care, including:
- clear communication and information sharing across agencies
- smooth transitions between services (such as maternity to health visiting, and early years to school)
- regular review of the family’s needs and progress

Question 2

2. Maternal and family mental health

Accepted Answer

Overview of high-impact area 2: ages 0 to 5

Perinatal mental health problems are common conditions that can be experienced by mothers and partners during the period from conception to the child’s second birthday. These conditions range from mild or moderate anxiety and depression to severe conditions such as postpartum psychosis. Approximately 10 to 20% of women experience a mental health disorder during pregnancy or after childbirth. According to MBRRACE-UK’s Saving Lives, Improving Mothers’ Care 2019 to 2021 report, mental health-related issues (including suicide) are the leading cause of maternal death between 6 weeks and one year after birth, accounting for 34% of those deaths.

The perinatal period brings significant change and can be a vulnerable time. There is increased risk of poorer perinatal mental health if parents experienced difficulties in pregnancy, trauma in childbirth or an unexpected event in their baby’s development. It is also a time when health inequalities can be exacerbated for those who experience discrimination, adversity and poor access to services.

Crucially, this is also a period of heightened parental motivation, when families are especially receptive to support and guidance that can improve their baby’s life chances. This makes it a prime opportunity to promote positive behaviour change, helping parents adopt healthy routines, strengthen relationships and make informed choices.

Why maternal and family mental health is important

Perinatal mental health problems have a profound impact on individuals, families and society. They are estimated by the Centre for Mental Health to cost the NHS and wider society approximately £8.1 billion annually with a significant proportion of this cost linked to adverse outcomes for children.

While access to specialist perinatal mental health services has steadily improved in recent years - with tens of thousands of women now receiving support for moderate to severe mental illness - many still face barriers to care. These include the following:

stigma and fear of judgement
concerns about child removal
cultural expectations and norms
language barriers
low awareness of symptoms and available support

Under the government’s 10 Year Health Plan, access to specialist perinatal mental health services continues to expand across all local areas. Building on previous transformation efforts, the national ambition remains to ensure that around 66,000 women a year can access timely, high-quality care for moderate to severe perinatal mental illness. This reflects a sustained commitment to prevention, integrated support and reducing inequalities in the critical early years.

The mental health of fathers and partners plays a crucial role in the wellbeing of the whole family. Poor mental health in partners can negatively affect maternal recovery, infant bonding and the overall emotional environment in the early years, according to NHS England’s Involving and supporting partners and other family members in specialist perinatal mental health services: good practice guide. Partners’ distress may present differently and often goes unrecognised due to stigma or lack of awareness. Encouraging partners to seek help through their GP, local therapy services or peer support is essential.

Early identification and timely access to care are essential during the perinatal period, as any woman may develop mental health problems during pregnancy or in the first year after birth. Health visitors and early years practitioners are uniquely positioned to recognise early signs of distress through their universal health and development reviews, which must be offered at specified time points, and ongoing contact with families. They play a vital role in:

promoting emotional wellbeing
identifying risk factors
facilitating access to appropriate support

The NHS has made significant progress in expanding access to specialist perinatal mental health services, with community teams now available in all local areas. Under the 10 Year Health Plan, the government has committed to transforming mental health services through 24/7 neighbourhood health centres and investing £120 million in dedicated mental health emergency departments. These reforms aim to ensure timely, equitable access to care and narrow mental health inequalities, including for women experiencing moderate to severe perinatal mental health difficulties.

There is evidence from Mind’s research into what causes perinatal mental health problems and Yang, Wu and Chen (see reference 2 in the Annex) that several factors can increase a woman’s vulnerability to perinatal mental health problems. These include the following:

previous history of mental health problems
family history of serious mental illness, such as bipolar disorder or postpartum psychosis
childhood abuse or neglect
domestic violence or interpersonal conflict
traumatic birth experiences
inadequate social support or isolation
alcohol or drug misuse
unplanned or unwanted pregnancy
migration or asylum-seeking status

ACEs such as abuse, neglect or parental mental illness can also increase vulnerability. Health visitors can mitigate these risks by building trusting relationships, offering trauma-informed care and supporting access to appropriate local services.

Traumatic birth experiences are another major contributor to poor maternal mental health. The final report of the All-Party Parliamentary Group on Birth Trauma’s inquiry, Listen to Mums: Ending the Postcode Lottery on Perinatal Care, cites that around one-third of women report childbirth as traumatic, and 4 to 5% go on to develop post-traumatic stress disorder (PTSD). Symptoms may include the following:

flashbacks and intrusive thoughts
anxiety and hypervigilance
emotional detachment or numbness

These symptoms can overlap with postnatal depression, and may affect parent-infant bonding and increase the risk of long-term mental health issues if left unaddressed.

Children of parents with untreated perinatal mental health problems are at increased risk of poor mental, physical and educational outcomes. Disrupted parent-infant bonding and insecure attachment can affect emotional regulation, behaviour and long-term wellbeing. Infant mental health is shaped by early relational experiences, and the first 1,001 days are critical for brain development and lifelong health.

The role of the health visitor in maternal and family mental health

As qualified SCPHNs, health visitors bring a unique blend of clinical expertise and public health insight. They are local leaders who work collaboratively across local authorities, primary care, maternity, mental health and specialist services. With advanced skills in assessing population health needs and understanding the social determinants of health, health visitors are well placed to drive innovation and influence service development across systems.

Their leadership helps ensure that perinatal mental health needs are identified early, and that women, partners and families receive timely, high-quality and evidence-based support - both within health visiting services and through wider integrated care pathways. All service delivery in health visiting recognises the impact of wider family wellbeing on infant outcomes.

Through universal health and development reviews, which must be offered at specified time points, health visitors establish trusting relationships that enable sensitive conversations about mental health and encourage disclosure of difficulties that might otherwise remain hidden. They:

provide evidence-based information on emotional and mental wellbeing
signpost to local services
work closely with GPs, maternity teams and specialist perinatal mental health services to ensure timely and appropriate support

In their leadership of skill mix teams, health visitors oversee safe delegation of care and ensure that families with additional needs receive targeted interventions. Their proactive, trauma-informed and relational approach helps strengthen parent-infant attachment, prevent the escalation of need, and reduce long-term health inequalities.

Specialist health visitors in perinatal and infant mental health further enhance this role by offering expert clinical input, consultation and workforce training, contributing to improved outcomes for families and communities.

The 4 levels of service offered to support maternal and family mental health

Community-level offer

At the community level, health visitors act as local public health leaders, working collaboratively across systems to promote maternal and family mental health. They help:

shape environments that support emotional wellbeing
reduce stigma
ensure families can access timely, appropriate support

Vitally, their work involves prevention and early intervention, helping to identify emerging needs before they escalate and promoting resilience across communities.

At the community level, health visitors:

work in partnership with local authorities, primary care, midwifery, secondary and specialist services and voluntary sector organisations to:
- identify and respond to local mental health needs
- influence service development and advocate for preventative approaches
- ensure perinatal and infant mental health is embedded in local strategies and early years planning
lead and support group-based interventions that promote emotional wellbeing and reduce isolation. These may include the following:
- peer support groups for mothers and fathers
- partners’ mental health and parenting sessions
- physical activity, mindfulness and wellbeing workshops delivered in collaboration with voluntary and community organisations, Best Start Family Hubs and neighbourhood health centres
raise awareness of wider determinants of mental health, providing information and signposting around:
- housing, benefits and financial insecurity
- relationship difficulties and social isolation
- access to culturally appropriate support
build community capacity through:
- supporting parent champions and peer-led initiatives
- partnering with faith groups, libraries and local charities to support wellbeing sessions
- promoting inclusive, trauma-informed environments that are accessible to all families
- reducing stigma and encouraging help-seeking by fostering safe, welcoming spaces for open conversations about mental health
highlight and support local and national campaigns, such as:
- Maternal Mental Health Awareness Week
- Infant Mental Health Awareness Week
- ICON: Babies cry, you can cope

Universal-level offer

At the universal level, health visitors provide every family with consistent, evidence-based support around maternal and family mental health as part of the healthy child programme. This includes the following:

holistic antenatal and postnatal health and development reviews to identify protective factors and early signs of maternal mental health difficulties, including anxiety, depression or perinatal mood disorders
use of evidence-based screening tools, such as the Whooley Questions for Depression Screening and the Generalised Anxiety Disorder 2-item (GAD-2), to identify emerging concerns in both mothers and partners. At subsequent contacts, tools such as the Edinburgh Postnatal Depression Scale or Patient Health Questionnaire (PHQ-9) may be used where appropriate
building trusting, therapeutic relationships during universal health and development reviews to encourage open conversations about emotional wellbeing, reduce stigma and promote help-seeking behaviours
providing evidence-based information and education about the emotional changes associated with pregnancy, birth and parenthood, including advice on self-care, sleep, coping strategies, and when and how to seek support and help
working in partnership with midwifery services to ensure joined-up care. Health visitors and midwives share relevant information and jointly follow up on emotional wellbeing needs identified during pregnancy and birth. This collaborative approach supports continuity of care and ensures that families receive consistent, timely support, in line with the National Institute for Health and Care Excellence’s (NICE) [NG194] Postnatal care guideline
observing parent-infant interactions and supporting parent-infant relationships, promoting secure attachment and responsive caregiving for both parental and infant mental health
working with, and signposting to, universal resources, including:
- GPs and primary care
- Best Start Family Hubs and neighbourhood health teams
- online mental health support and NHS talking therapies
- community groups and peer support programmes
incorporating NICE quality standard [QS115] Antenatal and postnatal mental health into all holistic assessments to support early identification and appropriate referral

Where commissioned, perinatal and infant mental health lead health visitors provide additional leadership, workforce development and service improvement to ensure a high-quality, consistent universal offer across services.

This proactive, preventative approach helps normalise conversations about mental health, supports emotional resilience during the transition to parenthood, and enables early identification of families who may benefit from targeted or specialist interventions. It reflects national priorities to embed prevention from conception, reduce inequalities and ensure every child has the best start in life.

Targeted-level offer

At the targeted level, health visitors apply their specialist skills and professional judgement to assess when families require more than the universal offer. While most families will only need the universal health and development reviews that must be offered at specified time points, others may present with mild to moderate maternal mental health needs or emerging risk factors that warrant additional personalised support.

As autonomous practitioners, health visitors draw on their expertise in public health, safeguarding and perinatal mental health to determine when targeted input is appropriate. This support is time limited and proportionate to need and may be safely delegated within skill mix teams where it is appropriate and safe to do so.

Health visitors remain accountable for assessing the level of input required, and ensuring that care is responsive, evidence based and aligned with the complexity of the family’s circumstances. This flexible approach is critical to preventing escalation, promoting recovery and strengthening protective factors, particularly considering the high rates of maternal morbidity and mortality linked to mental health during the perinatal period.

Targeted support may include:

additional home visits to offer reassurance and tailored support for maternal mental and emotional wellbeing that is flexible and responsive to the family’s needs and preferences. These visits also provide opportunities to observe and strengthen the parent-infant relationship, recognising its importance in promoting secure attachment and buffering the impact of emotional difficulties on the child
using evidence-based interventions, such as motivational interviewing to support behaviour change and self-efficacy, and solution-focused approaches to help parents manage anxiety, low mood or stress
supporting parent-infant interaction using tools such as parent-infant observation to explore relational patterns, and reflective functioning techniques to strengthen bonding and reduce the impact of emotional difficulties on the child’s development
working collaboratively with other professionals to ensure joined-up timely support, including:
- midwives and perinatal mental health midwives
- GPs and primary care
- community mental health services and NHS talking therapies
- Best Start Family Hubs and early help teams
facilitating access to targeted community resources, including:
- peer support groups and parenting programmes
- voluntary sector services offering emotional or practical support
- specialist services where risk factors are escalating
applying culturally sensitive, trauma-informed approaches to engage families who may face barriers due to language or communication needs, cultural beliefs or stigma around mental health, previous trauma or adverse experiences with services
monitoring progress and reviewing needs regularly, ensuring that families are supported to step up or step down between levels of service as appropriate

Where commissioned, perinatal and infant mental health lead health visitors may provide consultation and supervision to support practitioners delivering targeted interventions, ensuring consistency and quality across the service.

The targeted offer in health visiting ensures that families with additional needs receive timely, proportionate support that builds on their strengths and reduces the risk of poor outcomes. It reflects the importance of early intervention, integrated working and whole-family approaches in improving mental health and wellbeing during the perinatal period - not only for mothers, but also for fathers, partners and infants.

Support at this level is typically time limited, proportionate to need and may be delivered by the most appropriate member of the health visiting team.

Specialist-level offer

At the specialist level, health visitors play a crucial role in identifying and supporting families with complex or high-risk perinatal mental health needs. These may include:

severe mental illness
significant safeguarding concerns
co-existing vulnerabilities such as domestic abuse, substance misuse or trauma

Health visitors act as advocates, co-ordinators and skilled practitioners, ensuring that families receive the right care at the right time from the right service.

This involves:

identifying and supporting families to access specialist perinatal and infant mental health services for parents experiencing moderate to severe mental health conditions, such as postpartum psychosis, severe depression or anxiety, and complex trauma or PTSD following birth trauma
referring to and working in partnership with, where appropriate, specialist perinatal mental health services, including:
- community perinatal mental health teams
- specialist mental health midwives
- crisis teams
- secondary mental health services
- mother and baby units
acting as a vital link between families and services, ensuring timely referral and follow-up, information sharing and continuity of care, and advocacy for families navigating complex systems
supporting the development of multi-agency care plans, working closely with:
- social care and safeguarding teams
- early help and family support services
- child and adolescent mental health services (CAMHS) and infant mental health specialists
- voluntary and community sector organisations
providing direct support to families, such as:
- psychoeducation and emotional support
- guidance on managing mental health symptoms in the context of parenting
- support for parent-infant interaction and attachment
recognising and responding to the mental health needs of infants, particularly where parental mental illness may impact bonding, development or safety. Health visitors may liaise with early years services, infant mental health specialists or CAMHS to ensure appropriate support
using trauma-informed, culturally sensitive approaches to engage families who may be reluctant to access specialist services due to stigma, fear or previous negative experiences

Where commissioned, perinatal and infant mental health lead health visitors provide expert clinical leadership, consultation and supervision to support frontline practitioners working with complex cases. They also contribute to service development, workforce training and strategic planning to improve outcomes for families affected by severe perinatal mental illness.

The specialist offer in health visiting ensures that families with the most complex needs receive co-ordinated, compassionate and expert care, reducing the risk of harm and promoting recovery. It reflects the importance of integrated working, clinical leadership and whole-family approaches in safeguarding wellbeing and improving long-term outcomes for parents, partners and infants.

Question 3

3. Breastfeeding

Accepted Answer

Overview of high-impact area 3: ages 0 to 5

Breastfeeding is a cornerstone of early-life health intervention and an important public health priority with far-reaching implications. A systemic review from Victora, Bahl and others (see reference 3 in the Annex) indicates that breastfeeding significantly reduces infant morbidity and mortality by protecting against common infections, while also lowering the risk of chronic conditions such as obesity and type 2 diabetes later in life.

For mothers, it decreases the risk of breast cancer (see reference 4 in the Annex) and ovarian cancers (see reference 5 in the Annex), and supports postpartum recovery as described in NICE guideline [NG194] on postnatal care and NICE guideline [NG247] Maternal and child nutrition: nutrition and weight management in pregnancy, and nutrition in children up to 5 years.

NICE quality standard [QS37] Postnatal care states that health visitor services should ensure that healthcare professionals, including health visitors, are trained and competent to provide effective face-to-face feeding support.

The UNICEF UK Baby Friendly Initiative accreditation for community healthcare services recognises trusts that have embedded evidence-based standards into practice, ensuring all staff are trained to deliver consistent, high-quality support for breastfeeding and parent-infant relationships, thereby promoting optimal health and wellbeing outcomes.

This is supported through the Three year plan for maternity and neonatal services, which requires trusts to achieve the standard of the UNICEF UK Baby Friendly Initiative for infant feeding, or an equivalent initiative, by March 2027.

Why breastfeeding is important

The aforementioned analyses of research are the basis for NICE guidelines, which recommend exclusive breastfeeding for the first 6 months of life (see [NG194]), with introduction of solid foods from 6 months alongside continued breastfeeding for up to 2 years or beyond (see [NG247]).

This recommendation is supported by the Scientific Advisory Committee for Nutrition’s (SACN) review of the evidence, Feeding in the first year of life, which states that, for infants, breastfeeding:

promotes healthy infant brain development
protects against the risk of respiratory infections, gastroenteritis and ear infections
lowers the incidence of chronic conditions, such as type 2 diabetes and childhood obesity

For mothers, breastfeeding is protective against breast cancer, ovarian cancer and type 2 diabetes and improves post-partum recovery.

According to the Office for Health Improvement and Disparities’ (OHID) official statistics on Breastfeeding at 6 to 8 weeks after birth: annual data April 2023 to March 2024, the gap between breastfeeding rates at 6 to 8 weeks between the most and least deprived areas in England is decreasing but considerable variation persists. Improving breastfeeding rates in lower socioeconomic groups and young parents is a public health priority that can help to reduce health inequalities (see NICE guideline [NG194]).

Theoretical frameworks, such as attachment theory, support the idea that sensitive, responsive caregiving - including during feeding - lays the foundation for secure attachment relationships, which are linked to positive social, emotional and cognitive outcomes. UNICEF’s UK Baby Friendly Initiative promotes responsive feeding (recognising that feeds are not just for nutrition, but also for love, comfort and reassurance between baby and mother), which is beneficial for mother and infant, including for their attachment relationship. This is supported both by NICE guidelines [NG75] Faltering growth: recognition and management of faltering growth in children and [NG194], and the Feeding in the first year of life: SACN report referenced above.

Exclusive or predominant breastfeeding up to 12 months of age is associated with a decreased risk of dental caries in infants (see reference 6 in the Annex), and an association exists between breastfeeding and reduced risk of sudden unexpected deaths in infancy (see reference 7 in the Annex).

Breastfeeding supports self-regulation of appetite and slower weight gain. Breastfeeding for 3 months in the first year of a baby’s life (particularly among those who are predisposed to obesity) reduces the risk of obesity by 13% in later life (see reference 8 in the Annex).

Mothers who breastfeed benefit from a faster return to pre-pregnancy weight in the 6 to 8-week postpartum period and a lower body mass index (BMI) at one year postpartum (see reference 9 in the Annex).

NHS England’s Better Births: improving outcomes of maternity services in England - a five year forward view for maternity care highlighted the importance of breastfeeding and support. The best outcomes occur when midwives and health visitors work in partnership to support parents by providing expert advice and support to families. Developing these relationships enables difficulties to be identified early and help to be offered when needed.

The role of the health visitor in breastfeeding

Health visitors are qualified SCPHNs who play a critical role in supporting mothers, babies and families with breastfeeding. Their role is underpinned by public health principles with a focus on prevention, early intervention and reducing inequalities.

Health visitors are uniquely placed to do the following:

build trusting relationships with families during pregnancy, offering them an opportunity to learn about infant feeding, the benefits of breastfeeding and breast milk, the risks associated with not breastfeeding, and how to initiate and sustain breastfeeding. Health visitors’ ability to offer both informational and emotional support in the maintenance of breastfeeding, and the subjective experience of feeding an infant more generally, has been shown to support continued breastfeeding within the UK (see reference 10 in the Annex)
champion infant mental health and early attachment, using their expertise to articulate how breastfeeding supports sensitive, responsive parenting and promotes secure parent-infant relationships
offer supportive conversations that explore culturally sensitive beliefs about breastfeeding as well as the place of responsive, paced bottle feeding - whether with expressed breastmilk or formula - in the spectrum of feeding possibilities
engage with fathers, partners and other caregivers to discuss their unique role in supporting the mother-baby dyad (relationship) in breastfeeding, and their own contribution to nourishing their baby
help families navigate services by communicating across acute, specialist and community health services, as well as third sector and peer support, to ensure families receive co-ordinated, joined-up breastfeeding care
promote health equity, ensuring that services are accessible, inclusive and culturally sensitive - particularly for underserved families
support system leadership, contributing to local infant feeding and healthy weight early years strategies, ICSs and multi-agency planning to improve outcomes for families and children
identify and respond to safeguarding concerns, including domestic abuse, parental mental illness and substance misuse, ensuring timely referral and intervention
assure smooth service transitions and joined-up working between maternity services and health visiting to ensure families receive safe, personalised continuity of care from pregnancy and throughout the early postnatal period

The 4 levels of service offered to support breastfeeding

Community-level offer

Health visitors lead and contribute to population-level initiatives that address the wider determinants of health to reduce health inequalities. They are well placed to help create respectful environments where women feel safe and welcome to breastfeed. This includes the following:

Universal-level offer

At the universal level, health visitors adopt a Making Every Contact Count (MECC) approach, ensuring that every family receives meaningful strengths-based support to build their confidence and skills in feeding their baby. Health visitors’ critical role involves conducting sensitive conversations regarding breastfeeding, and providing tailored, accessible and culturally sensitive information to empower families to make well informed choices about feeding their baby.

Through the healthy child programme, all families are offered evidence-based information and support on breastfeeding, including guidance on:

whether their baby is feeding well
giving expressed breastmilk or formula milk from a bottle
navigating the transition to family foods from around 6 months of age

Every contact - during home visits, clinic or other community-based contacts - is an opportunity for health visiting teams to:

develop maternal confidence in breastfeeding by providing antenatal support and personalised information that is aligned with the baby’s developmental stage. NICE reinforces that face-to-face feeding support is a major component of support for breastfeeding (see guideline [QS37])
support informed decision-making, including around when to seek medical advice

During the antenatal health and development review, which must be offered to women after 28 weeks of pregnancy, health visitors use their specialist skills to:

give information about local health visiting and early years services available for those who are pregnant, including Best Start Family Hubs, local groups and classes
have a meaningful conversation about infant feeding that considers each mother’s individual needs, using a guiding style, open questions and reflections. UNICEF’s Baby Friendly Initiative guidance recommends that discussions aim to:
- prepare mothers for feeding and caring for their baby in ways that will optimise their own and their baby’s wellbeing
- explain how breastfeeding works, discuss any previous feeding challenges and convey how to begin breastfeeding successfully
- involve the baby’s father or mother’s partner and/or family members in the conversation, particularly the value of their involvement and support
- articulate the value of breastfeeding for protection, comfort and food for babies
- effectively communicate information about the benefits of breastfeeding, the risks of not breastfeeding and how parents know their baby is feeding well

Relevant resources can be found on the UNICEF and NHS websites:

During postnatal contacts, health visitors use their specialist skills to:

explore parents’ understanding of responsive infant feeding and the role this plays in developing a close and loving relationship with their baby
carry out a breastfeeding assessment at the new birth health and development review and subsequent postnatal contacts to ensure effective feeding is taking place and confirm the wellbeing of mother and baby
where issues are identified - for example, sore nipples, breast engorgement or mastitis - devise a plan of care with the mother (including family members if appropriate) and offer tailored information
liaise with other services as needed to ensure appropriate support is in place
if the family is giving their baby expressed breastmilk or formula in a bottle, carry out a bottle-feeding assessment, ensuring parents understand:
- how to express milk effectively and/or prepare formula safely
- the impact that giving milk from a bottle may have on breastfeeding
- how to bottle feed responsively
- pacing the feed according to the baby’s feeding cues
provide parents with information on selecting an infant formula, if they choose to use it, highlighting that infant formula must meet specific compositional regulations so all first-stage milks for use from birth for sale in the UK are suitable, regardless of brand or price
offer parents who are using infant formula information that first-stage formula is suitable for use throughout the first year of life and that there are no proven health benefits of switching to follow-on formula at 6 months
offer information and support with any feeding challenges - for example, posseting after feeds or possible reflux - making referrals for additional assessment or services as required
carry out growth monitoring using the Royal College of Paediatrics and Child Health’s (RCPCH) UK-WHO growth charts - guidance for health professionals and any locally agreed protocols, including monitoring faltering growth
support parents to access and navigate health services including local Best Start Family Hubs, clinics and breastfeeding support groups, the National Breastfeeding Helpline, NHS 111 and local pharmacy support
signpost parents to digital or web-based resources such as the NHS Best Start in Life website referenced above and Healthier Together - a parent-friendly, NHS-developed website offering accessible, evidence-based guidance on managing feeding, minor illnesses, understanding child development and preventing accidents
ensure parents understand safety issues relating to feeding, including:

Health visitors also offer anticipatory guidance on issues such as:

helping parents adapt their caregiving around feeding in a developmentally appropriate way, such as in relation to the introduction of a bottle or cup, and emerging signs of a baby’s readiness for solid foods
feeding when out and about with their baby, including information about local ‘breastfeeding welcome’ schemes
returning to work and the continuation of breastfeeding
feeding at night (signposting the Baby Friendly Initiative’s Sleep and night time resources)
supporting on any issue that the mother or family considers may be a barrier to ongoing breastfeeding
highlighting parent and family strengths, and resources to navigate any challenges, exploring what additional support or resources may be appropriate
assessing the influence of wider factors such as language, culture and previous healthcare experiences on each family’s understanding and engagement, personalising support and information appropriately to their needs
collecting and recording data on breastfeeding in line with local protocols

Targeted-level offer

At the targeted level, health visitors provide additional support to families identified as having increased vulnerability or risk factors that may impact their ability to manage their baby’s feeding safely and/or understand health information.

Health visitors provide the following types of targeted support. They:

identify and support high-risk groups
anticipate and respond to changing family circumstances, including the arrival of a new partner, parental mental or physical ill health or extended family visits, which may introduce new risks or disrupt routines
assess, at the antenatal health and development review, when a family may require additional support. This includes determining to what extent any family vulnerabilities may impact on the mother’s ability to feed her baby according to her wishes
carry out feeding assessments and respond to any feeding challenges. This may include giving information about and/or making referrals to other services - for example, a specialist infant feeding team or tongue tie assessment service
prescribe medications within the remit of their scope of practice under the Nursing and Midwifery Council’s Standards for prescribers, if they hold the appropriate qualification to do so
demonstrate alertness to the complex interplay between maternal mental health and breastfeeding experiences, and assess mothers’ emotional wellbeing, offering targeted interventions where appropriate and/or making referrals to specialist services according to local protocols and pathways

This targeted approach supports the 10 Year Health Plan’s commitment to early intervention and neighbourhood-based care, ensuring that families with greater needs receive proportionate and timely support to prevent escalation and reduce pressure on acute services. Support at this level is typically time limited, proportionate to need and may be delivered by the most appropriate member of the health visiting team.

Specialist-level offer

At the specialist level, health visitors support families where complex issues are present. This may include instances where health, developmental or safeguarding needs are found to be significantly impacting on the mother and/or baby (such as if the baby is exhibiting an inability to feed).

At this specialist level, health visitors:

assess the needs of every family at the antenatal health and development review to anticipate the need for additional support and/or services as soon as possible
assess infant feeding at each contact, as described above, offering additional contacts if appropriate to meet the assessed needs of the family
use local referral pathways to ensure mothers have access to specialist breastfeeding support such as:
- tongue tie and frenotomy assessments
- breast pump loan scheme access, peer support services or help with acquiring lactation aids, such as a supplemental nursing system
maintain contact with the family, offering support and collaborating with other services as appropriate
reduce unnecessary emergency attendances through education and anticipatory guidance

Question 4

4. Healthy weight and nutrition

Accepted Answer

Overview of high-impact area 4: ages 0 to 5

Healthy weight and nutrition in the early years are essential foundations for lifelong health and wellbeing. Establishing healthy eating patterns and maintaining a healthy weight from a young age provides children with the best start, protecting them from illness throughout childhood and into adulthood.

This involves supporting optimal growth, development and emotional resilience through balanced nutrition, physical activity and healthy lifestyle habits, which should be established during pregnancy and continue through to school entry.

Healthy weight is not just about preventing obesity - it is about ensuring that children are well nourished, physically active and growing along expected BMI centile ranges for their age and sex (as outlined in the UK-WHO growth charts linked in ‘3. Breastfeeding’ above). Nutrition in the first 1,001 days (from conception to age 2) plays a critical role in brain development, immune function and the prevention of both undernutrition and overweight. Breastfeeding, responsive feeding and the timely introduction of solid foods are major components of this foundation, according to the government’s The best start for life: a vision for the 1,001 critical days.

NICE guideline [NG247] on maternal and child nutrition provides evidence-based recommendations that underpin this approach. It:

highlights the importance of establishing healthy eating patterns from pregnancy through to early childhood
promotes exclusive breastfeeding for the first 6 months, where possible
supports parents and caregivers in making informed choices about complementary feeding
emphasises the role of healthcare professionals in delivering consistent, culturally sensitive advice that supports optimal growth and development

Why weight and nutrition is important

Establishing healthy eating patterns and maintaining a healthy weight from pregnancy through to school entry supports optimal brain development, emotional resilience and physical growth - while helping reduce health inequalities as early as possible in life.

Childhood obesity remains one of England’s most pressing public health challenges with strong links to deprivation and widening inequalities. Children from disadvantaged communities, those with overweight parents and some ethnic minority groups are disproportionately affected. The Obesity Profile: November 2024 update cites that, by the age of 11, obesity prevalence was 22.1% with rates significantly higher in the most deprived areas.

Living with obesity in early childhood is associated with increased risk of:

type 2 diabetes
cardiovascular disease
poor oral health
reduced quality of life

These health issues can impact educational attainment, emotional wellbeing and long-term life chances (see reference 11 in the Annex).

Changes in the BMI category of children between the first and final years of primary school, 2023 to 2024 also shows there is a clear link between high BMI and the prevalence of dental caries - even when deprivation is accounted for.

According to the Oral health survey of 5 year old children 2022, 1 in 4 5-year-olds in England starts school with tooth decay, and children living with obesity are more likely to experience oral health issues.

Nutrition in the first 1,001 days is especially important for immune function, brain development and long-term health, as stated in the government’s vision. Maternal obesity also presents risks during pregnancy and birth, including:

increased likelihood of complications
limited birthing options
adverse outcomes for babies such as stillbirth, congenital abnormalities and future obesity

Data from the National Child Measurement Programme, England, 2023 to 2024 school year shows that nearly 1 in 10 children are living with obesity at school entry. Longitudinal analysis confirms that children living with obesity rarely ‘grow out of it’ - highlighting the need for early, sustained intervention (see Changes in the BMI category of children between the first and final years of primary school, 2023 to 2024, linked above).

The government’s 10 Year Health Plan identifies tackling obesity as central to shifting the NHS towards prevention. This includes addressing root causes such as the food environment and supporting families earlier in life to raise the healthiest generation of children ever.

Obesity is a complex issue influenced by genetic, physiological, behavioural and environmental factors. Early years interventions that promote regular physical activity, healthy eating and emotional wellbeing are essential. Evidence from the UK Chief Medical Officers’ physical activity guidelines communications framework shows that higher levels of physical activity in young children are consistently associated with:

healthier weight
improved motor and cognitive development
better cardiometabolic outcomes

Government advice on a healthy, balanced diet is outlined in the Eatwell Guide, and the SACN report: feeding young children aged 1 to 5 years provides a robust framework for healthy growth and obesity prevention.

Supporting families to establish healthy eating patterns, encourage physical activity and build emotional resilience in the early years is crucial to improving long-term outcomes and reducing health inequalities.

The role of the health visitor in weight and nutrition

As qualified SCPHNs, health visitors are uniquely positioned to support families from pre-conception through to school entry. Their role is central to the:

early identification of health needs
promotion of healthy lifestyles,
prevention of childhood obesity and related health inequalities

Through the healthy child programme, health visitors provide consistent, evidence-based advice on nutrition, physical activity and oral health. They use behaviour change techniques such as motivational interviewing during health and development reviews and opportunistic contacts to support families in making sustainable lifestyle changes. Health visitors play a pivotal role in the following:

primary prevention and early identification
promoting healthy weight from pre-conception onwards, recognising the impact of both maternal and paternal health on child outcomes
collaborating with GPs, midwives and other professionals to support healthy weight gain during pregnancy
monitoring growth using UK-WHO charts to identify early deviations before school age
supporting data collection to inform local and national understanding of obesity trends

Health visitors empower families to make healthier lifestyle choices by:

building health literacy and confidence around nutrition, feeding and physical activity
providing culturally sensitive support that reflects diverse family structures and dietary practices
involving both parents, recognising that paternal weight is a predictor of child obesity
encouraging regular physical activity and promoting its developmental benefits
connecting families with local opportunities for active play, including Best Start Family Hubs and community programmes

They also address wider determinants of health by:

assessing food insecurity, housing and access to safe outdoor spaces
advocating for healthy environments and shaping services to meet community needs
working with early years settings and local authorities to reinforce healthy messages and make healthy choices easier

Health visitors are a trusted and accessible part of the workforce. Their universal reach and continuity of contact enable early intervention at scale - supporting families before weight-related complications become entrenched.

By helping families build healthy habits from the start, health visitors are vital in reducing inequalities and supporting the government’s ambition to raise the healthiest generation of children.

The 4 levels of service offered to support healthy weight and nutrition

Community-level offer

At a population level, health visiting teams play a vital role in building community capacity to support healthy eating, physical activity, and healthy growth and weight outcomes. Their leadership and expertise in public health and child development enables them to shape environments where families live, work and grow - ensuring these settings promote healthy choices and reduce inequalities.

As part of the community-level offer, health visitors:

partner with local authorities, early years settings, Best Start Family Hubs, neighbourhood health centres, schools and voluntary organisations to co-design and deliver community-led initiatives, such as ‘cook-and-eat’ groups, physical activity programmes and safe active play initiatives, and support for families on low incomes to make healthy food choices within a budget
promote consistent, evidence-based messages on nutrition, physical activity and oral health across early years services - this includes advocating for healthy snacks and drinks, and supporting initiatives to reduce tooth decay
support the implementation of national frameworks, such as the UNICEF UK Baby Friendly Initiative, to embed healthy feeding and nutrition practices in community and early years settings

Universal-level offer

The universal reach of health visiting through the healthy child programme provides a vital opportunity to promote healthy weight and nutrition from the earliest stages of life. Health visiting teams deliver consistent, preventative support to all families - helping to establish healthy routines and reduce inequalities before problems become entrenched.

At the universal level, health visitors:

By reinforcing these messages during health and development reviews and other universal contacts, health visitors empower parents to establish healthy routines and environments that enrich their child’s long-term health and contribute to the government’s ambitions in the 10 Year Health Plan.

Targeted-level offer

Health visitors play a crucial role in identifying families who may be at greater risk of poor health outcomes and providing tailored support to address specific needs. This targeted offer is central to reducing health inequalities and ensuring that all children can maintain or achieve a healthy weight and positive developmental outcomes.

As trusted professionals working closely with families from pregnancy and throughout early childhood, health visitors are uniquely placed to:

identify families who need additional support
co-ordinate or deliver personalised interventions that address both individual behaviours and the wider determinants of health

Support at this level is typically time limited, proportionate to need and may be delivered by the most appropriate member of the health visiting team.

At the targeted level, health visitors:

use professional judgement and assessment tools during universal and targeted contacts to identify families who may benefit from additional support - such as those experiencing food insecurity, housing instability, low health literacy or parental obesity
determine the most appropriate level of input, which may include delegating specific tasks to other members of the health visiting team. For example:
- a nursery nurse may deliver a short-term programme of home visits focused on basic food advice, label reading and cooking skills
- a staff nurse may provide targeted support around physical activity or oral health
- the health visitor retains oversight, ensuring the intervention is proportionate, evidence based and responsive to evolving needs
offer tailored interventions to families with specific challenges, including:
- feeding difficulties, ‘fussy’ eating or excessive weight gain in infancy
- breastfeeding and weaning support (see ages 0 to 5 high-impact area ‘3. Breastfeeding’ above)
- support for parents with mental health concerns or learning needs
- culturally appropriate advice for families from diverse backgrounds
work in partnership with other services, including midwives, GPs, early years practitioners and voluntary sector organisations, to provide co-ordinated care and ensure families are connected to the right support at the right time
refer, facilitate access to or directly deliver targeted programmes, such as:

Through the provision of personalised, culturally sensitive and non-judgemental support, health visitors help families to overcome barriers to healthy living and build the confidence and practical skills needed to make sustainable lifestyle changes.

By working collaboratively with other professionals - through neighbourhood health clinics, Best Start Family Hubs and wider early years networks - health visitors ensure families receive holistic, joined-up and accessible support tailored to their needs. This place-based approach recognises that health outcomes are shaped by neighbourhood-level factors and requires co-ordinated community responses.

The targeted offer ensures that timely identification of need leads to the delivery of meaningful, proportionate support by the most appropriate member of the health visiting team. This approach contributes to the government’s 10 Year Health Plan and its ambition to reduce inequalities.

Specialist-level offer

A small number of families require specialist interventions to support healthy weight and nutrition due to complex needs or co-existing challenges. Health visitors play a major role in identifying these families as early as possible and ensuring they are supported through appropriate, co-ordinated care.

At the specialist level, health visitors:

follow local pathways to refer families to multidisciplinary teams, including paediatrics, dietetics, speech and language therapy, and specialist child weight management services. These services are particularly important for children with complex feeding issues, faltering growth or severe obesity, and should be accessible in community settings
recognise when psychological support is needed, such as in cases involving disordered eating, body image concerns or parental mental health issues. This may include referral to CAMHS, perinatal mental health teams or clinical psychology
support families receiving specialist care by reinforcing core messages and using strengths-based approaches to ensure information is understood and acted upon. Health visitors help families implement complex care plans - particularly where low health literacy, emotional distress and/or diverse cultural backgrounds and language barriers exist
identify wider social determinants that may impact a child’s growth and weight, and work collaboratively across neighbourhood health clinics and Best Start Family Hubs to ensure families receive wraparound support. This includes advocating for families experiencing poverty, housing instability or food insecurity
refer and facilitate access to locally commissioned services that complement specialist care - such as ‘cook-and-eat’ programmes, parenting support groups, community-based physical activity initiatives, and benefits or housing advice. These services help families build practical skills and confidence to adopt sustainable lifestyle changes
use national tools and resources, such as the NHS Children’s healthier eating toolkit, to provide consistent, evidence-based advice that aligns with specialist recommendations and supports whole-family engagement
ensure, by acting as a consistent point of contact and advocate for the family, that even the most complex cases are supported in a holistic, family-centred way. Where appropriate, they may delegate specific tasks to other members of the health visiting team - ensuring care is proportionate, timely and delivered by the most suitable practitioner

Question 5

5. Health literacy, managing minor illnesses and reducing accidents

Accepted Answer

Overview of high-impact area 5: ages 0 to 5

Improving health literacy, managing minor Illnesses and reducing accidents focuses on equipping parents and carers with the knowledge, confidence and practical skills to keep their children safe and healthy. It supports families to:

recognise signs of illness
manage minor ailments at home
access appropriate services
reduce risks in the home environment

Health literacy is fundamental to all high-impact areas. It refers to a parent’s ability to access, understand and use health information to make informed decisions. It also includes organisational health literacy - the responsibility of services to communicate clearly, inclusively and accessibly.

Health visitors play a major role in both developing personal health literacy and advocating for improved service communication. By promoting safe practices and timely care-seeking, they:

help prevent avoidable harm
reduce pressure on urgent care
support safer childhoods

This high-impact area reflects the principles of proportionate universalism - recognising that, while all families benefit from support, those with greater needs require more intensive input. It also emphasises culturally sensitive and trauma-informed practice, ensuring that health messages are inclusive and relevant across diverse communities.

Why health literacy is important

Improving health literacy is fundamental to reducing health inequalities, preventing avoidable harm and building resilient, informed communities. It enables families to manage minor illnesses confidently, navigate health services appropriately and create safer home environments.

The impact of poor health literacy is significant because:

Poor oral health is another area where improved health literacy can reduce harm and cost. The Oral health survey of 5 year old schoolchildren 2024 stated that, in 2024, 22.4% of 5-year-old children in England had tooth decay. It also showed that children living in the most deprived areas were:

more than twice as likely to have experienced dental decay (32.2%) compared with those in the least deprived areas (13.6%)
more than 3.5 times more likely to have experienced decay-related extractions

Hospital tooth extractions in 0 to 19 year olds 2024 statistics reveal that, in 2023 to 2024, decay-related tooth extractions among children aged 0 to 19 cost approximately £45.8 million.

In response, the government has introduced a national supervised toothbrushing programme for 3- to 5-year-olds in early years settings in the most deprived areas.

Improving both individual and organisational health literacy has the potential to:

reduce pressure on emergency services
promote safer environments
contribute to the reduction of health inequalities

This focus on prevention aligns with the government’s 10 Year Health Plan and ‘Giving every child the best start in life’ strategy, which prioritise neighbourhood-based support and strengthened early years services.

The role of health visitors in health literacy

As qualified SCPHNs, health visitors bring a unique blend of clinical expertise and public health insight. They are local leaders who work collaboratively across local authorities, primary care, maternity, community and specialist services.

Health visitors support both individual behaviour change and system-level improvements, ensuring families receive proportionate, inclusive and accessible support. They:

Health visitors lead on assessment and planning, but delivery may be delegated to the most appropriate member of the health visiting team - including nursery nurses, staff nurses, or early years practitioners. This ensures support is proportionate, timely and matched to the family’s level of need.

By combining clinical leadership with a whole-team approach, health visitors ensure that health literacy, illness management and accident prevention are embedded across early years systems - contributing to safer, healthier childhoods and reducing pressure on urgent care.

The 4 levels of service offered to improve health literacy, manage minor illnesses and reduce accidents

Community-level offer

At the community level, health visitors lead and contribute to population-wide initiatives that promote child safety, reduce health inequalities and strengthen protective factors across neighbourhoods. This work focuses on creating supportive environments, improving health literacy and addressing the broader social determinants of health.

This includes the following:

promoting community health literacy by supporting initiatives that make health information more accessible, inclusive and culturally relevant. This includes working with local partners to develop and share clear, understandable resources that empower families to reach informed decisions about their children’s health and safety
multi-agency collaboration with housing teams, fire and rescue services, Best Start Family Hubs, social care and voluntary sector organisations to promote accident prevention, home safety schemes and community resilience
influencing local policy and commissioning by highlighting the impact of poor housing, overcrowding and environmental hazards on child health and development, and advocating for systemic changes that support safer living conditions
building community capacity through co-production with families, community leaders and grassroots organisations. This helps to deliver culturally sensitive health promotion and safety campaigns that reflect the lived experiences of diverse communities
acting as a bridge between health services and community groups, signposting families to local resources, and strengthening social support networks that protect child wellbeing and reduce reliance on emergency services
advocating for safe and secure housing - particularly for families in temporary, overcrowded or unsuitable accommodation - and working with local authorities to ensure appropriate safety measures are implemented

While health visitors lead this work, delivery may be supported by the wider health visiting team, ensuring that community-level initiatives are inclusive, proportionate and responsive to local need.

Universal-level offer

Health visitors use an MECC approach to deliver consistent, tailored advice during every universal contact. They assess parental health literacy and ensure advice is accessible, culturally relevant and strengths based.

Support is delivered by the most appropriate member of the health visiting team, with the health visitor leading assessment and oversight. This support includes:

discussing illness recognition, safe use of medicines and appropriate use of NHS 111, GP or pharmacy services, and building parental confidence in managing minor illnesses
providing anticipatory guidance during health and development reviews offered at specified time points. This helps parents adapt the home environment as their child grows and becomes more mobile, supporting accident prevention and safe play
promoting home safety practices, including safe sleep, secure storage of medications and cleaning products, and fall prevention
encouraging immunisations and good oral health practices, and reinforcing safety messages during developmental assessments, reviews and group activities
prescribing qualifications (where applicable) to support symptom management for conditions such as asthma or eczema. This helps families stabilise symptoms and avoid escalation
providing advice on risks related to alcohol or substance misuse in the home, particularly where it may impact parenting or child safety
educating and signposting families to trusted resources and combatting misinformation. This includes promoting:
- the Best Start in Life website and email campaigns
- Best Start Family Hubs and community support
- NHS baby care guidance
- Healthier Together
- ICON: Babies cry, you can cope
- the Lullaby Trust’s Safer sleep for babies information

By embedding health literacy and safety messages into every universal contact, health visitors empower families to make informed decisions, reduce avoidable harm and build safer home environments - contributing to healthier childhoods and reduced pressure on urgent care services.

Targeted-level offer

At the targeted level, health visitors provide enhanced support to families facing increased vulnerability or risk factors that may affect their ability to manage minor illnesses, understand health information or maintain a safe and stable home environment. This level of service is designed to address the needs of families experiencing complex challenges, ensuring they receive timely, proportionate and culturally appropriate support.

At the targeted level, health visitors:

monitor and respond to changing family dynamics, such as the arrival of a new partner, parental illness or extended family visits, which may introduce new risks or disrupt routines
analyse patterns of A&E or urgent care use for children aged 0 to 5 to identify families who may need additional support. Repeated attendances may signal underlying issues such as low health literacy, parenting challenges or safeguarding concerns
deliver tailored health education and anticipatory guidance, using culturally sensitive resources and communication methods to ensure families understand and engage with the information provided
use a strengths-based approach to support families to develop skills in identifying and assessing potential risks that emerge in new settings or as their baby develops. They do this by working alongside families to mitigate the risks and seek help and support when needed
delegate delivery of targeted interventions to the most appropriate member of the health visiting team. For example:
- a nursery nurse may provide home-based sessions on home safety, managing minor illness or accessing local services
- a staff nurse may support symptom management or reinforce safety guidance during follow-up visits
- the health visitor retains oversight, ensuring interventions are proportionate, evidence-based and responsive to changing needs

This targeted approach aligns with the 10 Year Health Plan’s commitment to early intervention and neighbourhood-based care. By identifying and supporting families with greater needs, health visitors help prevent escalation, reduce pressure on acute services and promote better long-term outcomes for children and families.

Support at this level is typically time limited, proportionate to need and may be delivered by the most appropriate member of the health visiting team.

Specialist-level offer

At the specialist level, health visitors provide intensive, personalised support to families where complex health, developmental or safeguarding needs significantly impact their ability to manage minor illnesses, understand health information or maintain a safe home environment. This includes children with chronic conditions or disabilities and/or those living in high-risk circumstances.

As part of the specialist-level offer, health visitors:

follow up on serious or repeated emergency presentations, including delayed or unexplained injuries, in line with safeguarding protocols. This ensures families receive the right support to reduce future risk and improve understanding of when and how to seek appropriate care
support families of children with chronic conditions or SEND through activity such as the following:
- enhancing parental understanding of the child or young person’s condition and symptom management
- engaging with the child or young person to develop their understanding and ability to manage their health condition
- using motivational interviewing skills to support behaviour change, particularly where compliance with treatment is challenging
- promoting the safe use of prescribed treatments and medical equipment
- reducing unnecessary emergency attendances through education and anticipatory guidance
- ensuring eligible families can access the supervised toothbrushing programme and understand its benefits
work with families facing complex vulnerabilities, such as domestic abuse, substance misuse or housing instability, where these factors may compromise parenting capacity or home safety, and encouraging access to other services to provide a multi-agency response
deliver intensive, tailored health education to improve health literacy in families with significant barriers to understanding, enabling them to better act on health advice
co-ordinate with multi-agency teams to ensure families receive holistic, joined-up care that addresses both clinical and environmental risks to child health and safety (in line with NHS England Guidance on neighbourhood multidisciplinary teams for children and young people)

While the health visitor leads assessment and care planning, delivery may be supported by the wider health visiting team - ensuring interventions are proportionate, timely and matched to the family’s level of need.

This specialist-level support reflects the 10 Year Health Plan’s commitment to personalised, integrated care. By equipping families - particularly those with complex needs - with the knowledge, confidence and support to keep their children safe and well, health visitors play a vital role in preventing avoidable harm and reducing reliance on acute services.

Question 6

6. Healthy, well and ready to learn

Accepted Answer

Overview of high-impact area 6: ages 0 to 5

This area focuses on ensuring children are physically, emotionally and socially prepared to thrive by the time they reach school age. It recognises that the first 1,001 days, from conception to age 2, represent a critical window of rapid brain development, laying the foundation for lifelong health, emotional wellbeing and learning.  

Secure relationships, responsive caregiving and positive parental mental health are fundamental to shaping school readiness. Physical, emotional and social development are deeply interconnected - strengthening one reinforces the others. 

A central priority within this high-impact area is reducing the ‘word gap’: the disparity in early vocabulary and communication skills between children from different socioeconomic backgrounds. According to the government’s Development Matters guidance, by the age of 5, most children understand around 10,000 words, but those from disadvantaged backgrounds may know significantly fewer, impacting their ability to learn, socialise and thrive.

This high-impact area supports the government’s ‘Giving every child the best start in life’ strategy, which prioritises early years development and aims to ensure every child reaches school age with the cognitive, social, emotional and physical skills to succeed. 

Early intervention and prevention are essential, providing timely, evidence-based support to reduce risks and strengthen protective factors. This includes:

promoting language-rich environments
supporting parental wellbeing
ensuring access to services before challenges escalate

To increase the number of 5-year-olds achieving a good level of development, delivery should be collaborative across health and education - including nurseries, childminders, schools, health services, Best Start Family Hubs, libraries and community groups. Together, these partners can make measurable differences in narrowing inequalities and ensuring all children are healthy, well and ready to learn. 

Why health, wellbeing and readiness to learn is important 

Many children enter reception class without basic communication, self-care and emotional regulation skills. These gaps are. according to the Department for Education’s Early years child development training, often preventable and largely reflect inequalities in access to supportive home environments, early education and health services.  

By promoting children’s learning alongside their health and wellbeing, health visitors can: 

narrow inequalities between children from different socioeconomic backgrounds, ensuring that all children are set up to thrive
improve educational attainment and longer-term chances
reduce demand on specialist health, education and social care services

This work is underpinned by a commitment to tackling disadvantage, ensuring that children with SEND and those from underserved backgrounds benefit as well as their peers. The goal is not only to raise standards universally, but to level the playing field so that every child has an equal opportunity to succeed. 

Supporting early development - particularly in communication and language, personal, social and emotional development, and physical development - has profound long-term benefits. Timely, evidence-based support in the early years contributes to better outcomes across the life course, making it not only vital for children and families but also a cost-effective public health intervention. 

The health visitor’s role in health, wellbeing and readiness to learn

Health visitors, as qualified SCPHNs, build trusted relationships with families and offer universal access during a child’s earliest years. Working across health, education and social support, they are uniquely placed to identify concerns early, tailor support to individual needs, and connect families with the right help - before challenges become entrenched. 

Using expert assessments, and a proactive and preventative approach, health visitors: 

While the health visitor leads assessment and planning, delivery may be delegated to the most appropriate member of the health visiting team - including nursery nurses, staff nurses and early years practitioners. This ensures support is proportionate, timely and matched to the family’s level of need. 

Health visitors play a central role in delivering accessible, integrated care from pregnancy to age 5 - including maternity and early years services - and promoting the uptake of high-quality early education and childcare. By guiding families towards these opportunities and advocating for equitable access, they contribute directly to the priorities outlined in the ‘Giving every child the best start in life’ strategy and 10 Year Health Plan. This helps to reduce inequalities, promote wellbeing and ensure every child is ready to learn and thrive.

The 4 levels of service offered to support health, wellbeing and readiness to learn

Community-level offer 

Health visitors act as public health leaders within the early years system, embedding health and wellbeing priorities into place-based initiatives that promote school readiness and holistic child development. Their leadership helps shape environments where children can thrive - regardless of background. 

At the community level, health visitors: 

While health visitors lead this work, delivery may be supported by the wider health visiting team - ensuring that community-level initiatives are inclusive, proportionate and responsive to local need. 

By embedding themselves in local systems and leveraging community assets, health visitors support the place-based prevention approaches championed in the 10 Year Health Plan. Their work helps to break the link between a child’s background and their future success - ensuring that every child, regardless of starting point, has the opportunity to thrive. 

Universal-level offer 

The universal offer - as outlined in the Delivery of the healthy child programme guidance and reinforced by ‘Giving every child the best start in life’ - ensures that all families receive consistent, preventative support during the critical early years, forming a foundation for lifelong health, wellbeing and learning. 

The universal offer includes the following: 

use of health and development reviews, which are offered at 5 specific time points, to undertake holistic assessments of children’s health, development and home learning environments, and identify emerging needs using developmental tools such as the ASQ and ASQ:SE
promotion of responsive caregiving from birth, encouraging attuned interactions, understanding baby’s cues and nurturing care that supports early brain development
support for language-rich, nurturing environments through everyday interactions like talking, reading, singing and play. These are vital for brain development and early communication
identification of parents who may require additional support due to their own communication needs
promotion of healthy routines around sleep, nutrition, physical activity and screen use, underpinning emotional wellbeing and learning readiness
early support for behavioural concerns, helping parents manage issues that may impact school readiness and long-term outcomes
proactive connection to national and local resources, including Best Start in Life, Tiny Happy People, library services, Best Start Family Hubs and parenting programmes
collaboration with midwives, GPs, early years providers and local authorities to ensure continuity of care, consistent messaging and early co-ordination of support for children with additional needs

While health visitors lead assessment and planning, delivery may be delegated (where permitted) to the most appropriate member of the health visiting team - ensuring support is proportionate, timely and matched to family need. 

This universal offer:

enables early identification and intervention
helps close the gap in opportunity
supports the ambitions of the ‘Giving every child the best start in life’ strategy

The aim is to ensure that every child has the opportunity to grow, play, learn and thrive.   

Targeted-level offer 

For families where developmental delays or social risk factors are emerging, health visitors provide targeted, time-bound support that prevents escalation and promotes resilience. This includes:

early identification of sensory impairment, speech and language delay or emotional needs
support for parenting and home learning
co-ordination with appropriate local services such as Best Start Family Hubs

At the targeted level, health visitors: 

use professional clinical judgement alongside developmental tools (such as ASQ, ASQ:SE, and the Early Language Identification Measure (ELIM)) to:
- identify children who may benefit from additional, focused support
- provide clinical consistency and structured insights into a child’s developmental progress and social-emotional wellbeing
deliver or co-ordinate short-term, tailored interventions to promote speech, language and communication, emotional regulation and parental confidence
work directly with parents to promote responsive caregiving and strengthen home learning environments
refer families to appropriate local services, including:
- audiology, ophthalmology or speech and language therapy
- early years inclusion teams and targeted parenting programmes (such as the Incredible Years or Solihull Approach)
- Best Start Family Hubs and community groups for peer support and social connection
address wider social and environmental challenges, such as housing insecurity, financial stress or isolation, through signposting or social prescribing
encourage and support transitions into early years settings, promoting uptake of high-quality education and childcare, and ensuring children with additional needs access appropriate support before starting school

While health visitors lead assessment and planning, delivery may be delegated to the most appropriate member of the health visiting team, such as:

a nursery nurse supporting home-based play and language activities
a staff nurse reinforcing health routines and developmental guidance
an early year’s practitioner facilitating group sessions that promote school readiness

This ensures support is proportionate, timely and matched to the family’s level of need. 

The targeted offer equips health visitors to deliver focused, proportionate support to families with emerging needs, identifying concerns early, co-ordinating timely interventions, and helping to reduce preventable inequalities in child development and outcomes. Support at this level is typically time limited, proportionate to need and may be delivered by the most appropriate member of the health visiting team. 

Specialist-level offer 

Health visitors play a vital role in supporting families with complex or ongoing needs.

At this level, health visitors ensure timely identification, co-ordination of care and sustained engagement to meet each family’s unique needs. 

Health visitors:

identify and refer children for multidisciplinary assessment (such as to neurodevelopmental pathways, community paediatrics, speech and language therapy or CAMHS)
collaborate with professionals such as educational psychologists, speech therapists, early years inclusion teams and safeguarding leads to co-create plans that promote school readiness and wellbeing
reinforce strategies at home, helping parents implement specialist advice through strengths-based, inclusive approaches that build confidence and resilience
act as a trusted advocate, guiding families through complex systems and connecting them to wraparound services that address both clinical and environmental needs

Each Best Start Family Hub will have a named practitioner responsible for supporting children with additional needs and their families. Health visitors work alongside them to ensure smooth transitions between services, strengthening early identification and access to appropriate support, whether health, education or social care.

They also contribute to multi-agency forums, such as child protection conferences and TAF meetings, embedding their expertise throughout a child’s early years. 

This integrated model reflects the ambitions of the ‘Giving every child the best start in life’ strategy and 10 Year Health Plan, prioritising inclusive, sustained support for families with the most complex needs.

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1. The transition to parenthood

Overview of high-impact area 1: ages 0 to 5

Why the transition to parenthood is important

Handover from maternity to health visiting services

The role of the health visitor in the transition to parenthood

The 4 levels of service offered during the transition to parenthood

Community-level offer

Universal-level offer

Targeted-level offer

Specialist-level offer

2. Maternal and family mental health

Overview of high-impact area 2: ages 0 to 5

Why maternal and family mental health is important

The role of the health visitor in maternal and family mental health

The 4 levels of service offered to support maternal and family mental health

Community-level offer

Universal-level offer

Targeted-level offer

Specialist-level offer

3. Breastfeeding

Overview of high-impact area 3: ages 0 to 5

Why breastfeeding is important

The role of the health visitor in breastfeeding

The 4 levels of service offered to support breastfeeding

Community-level offer

Universal-level offer

Targeted-level offer

Specialist-level offer

4. Healthy weight and nutrition

Overview of high-impact area 4: ages 0 to 5

Why weight and nutrition is important

The role of the health visitor in weight and nutrition

The 4 levels of service offered to support healthy weight and nutrition

Community-level offer

Universal-level offer

Targeted-level offer

Specialist-level offer

5. Health literacy, managing minor illnesses and reducing accidents

Overview of high-impact area 5: ages 0 to 5

Why health literacy is important

The role of health visitors in health literacy

The 4 levels of service offered to improve health literacy, manage minor illnesses and reduce accidents

Community-level offer

Universal-level offer

Targeted-level offer

Specialist-level offer

6. Healthy, well and ready to learn

Overview of high-impact area 6: ages 0 to 5

Why health, wellbeing and readiness to learn is important

The health visitor’s role in health, wellbeing and readiness to learn

The 4 levels of service offered to support health, wellbeing and readiness to learn

Community-level offer

Universal-level offer

Targeted-level offer

Specialist-level offer

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Why health, wellbeing and readiness to learn is important 

Community-level offer 

Universal-level offer 

Targeted-level offer 

Specialist-level offer 