Guidance

Introduction to the high-impact areas

Published 6 February 2026

Applies to England

Background and purpose

The high-impact areas are nationally recognised priorities within the healthy child programme.

Commissioners should ensure that they are commissioning public health nursing teams for those aged 0 to 19 to address these priorities locally - see the Healthy child programme: commissioning public health nursing services guidance for more details on this.

The high-impact areas enable the shaping of service delivery to meet public health priorities and improve outcomes for babies, children, young people and families - refer to the Delivery of the healthy child programme guidance for more information on service delivery.

The healthy child programme is the national universal public health framework for improving the health and wellbeing of babies, children and families from pregnancy through to age 19, or age 25 for care leavers or those living with special educational needs and disabilities (SEND) - this is known as the ‘0 to 19 pathway’. The programme provides a structured schedule of evidence-based health and development reviews, health needs assessments and interventions, led by qualified specialist community public health nurses and supported by skill mix teams.

The high-impact area framework complements the healthy child programme guidance by translating its principles into actionable priorities across the 0 to 19 pathway. It helps services:

• identify population needs
• align resources
• ensure that support is tailored, equitable and responsive to local context

This alignment enables practitioners to focus delivery where it can have the greatest impact, and ensures that babies, children, young people and families receive the right support at the right time.

The healthy child programme is underpinned by 10 high-impact areas in total:  

• 6 high-impact areas for children aged 0 to 5
• 4 high-impact areas for school-aged children (aged 5 to 19, or up to the age of 25 for care leavers and those with SEND)

These areas cover topics ranging from supporting physical, mental and emotional wellbeing through to transitions and resilience, with the aim of helping children become ready to learn, grow confidently and thrive. Aligning service delivery with the high-impact areas ensures that practitioners not only meet statutory health and development review requirements but also provide proportionate, tailored support to families based on need.

This refreshed framework retains the 6 high-impact areas for health visiting and aligns with the School and Public Health Nurses Association (SAPHNA) vision model of school nursing, School nursing: creating a healthy world in which children can thrive - a service fit for the future, which morphs the original 6 high-impact area into 4 integrated domains, offering a more holistic, strengths-based approach to meeting the needs of children and young people aged 5 to 19.

Terminology and wider products

See the ‘Terminology’ and ‘Wider healthy child programme publications’ sections of the introduction to the Delivery of the healthy child programme guidance to read more about the:

• specific terms used in this guidance and their definitions
• relationship between the various healthy child programme publications and their target audiences

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

The early years, from conception to age 5, are a time of monumental importance in a child’s life. During this time, brain development is rapid, secure attachments are forming, and relationships begin to shape a child’s emotional and social world.

Health visitors and their teams play a vital role in engaging with expectant parents and families, using their expertise in holistic assessment, public health promotion, child development and early intervention approaches to support parents and enable babies and children to thrive. 

The high-impact areas for health visiting are as follows.

1. The transition to parenthood 

This high-impact area involves:

• working closely with maternity services to ensure a seamless and safe transition between services
• helping families prepare for and adjust to life with a new baby
• promoting immunisation uptake, secure attachment and responsive parenting from the earliest possible stages

2. Maternal and family mental health 

This high-impact area involves:

• identifying and responding to perinatal mental health needs
• promoting emotional wellbeing
• reducing the impact of parental mental illness on child development

3. Breastfeeding 

This high-impact area involves:

• promoting breastfeeding initiation and continuation
• offering practical support
• addressing barriers to improve infant nutrition and bonding

4. Healthy weight and nutrition 

This high-impact area involves encouraging healthy eating habits, physical activity and responsive feeding to support healthy growth and prevent childhood obesity. 

5. Health literacy, managing minor illnesses and reducing accidents 

This high-impact area involves empowering parents with the knowledge and confidence to:

• manage common childhood illnesses
• access appropriate care
• create safe home environments

6. Healthy, well and ready to learn

This high-impact area involves promoting early language development, school readiness and equitable developmental outcomes - particularly among children at risk of falling behind. 

High-impact areas for school nursing (ages 5 to 19)

Between the ages of 5 and 19, children and adolescents go through several major transition points that include physical, emotional, social and cognitive changes.

School nurses use their expertise in holistic assessment and public health to:

• identify health needs early
• engage children and their families in health promotion, prevention and early intervention approaches

This enables children and young people to thrive and prevents issues from escalating. 

1. Physical, mental and emotional health and wellbeing 

This high-impact area involves supporting children and young people to make informed, positive choices about their health, including:

• maintaining a healthy weight
• increasing physical activity
• improving oral health
• reducing the harms of tobacco, alcohol and substance misuse

School nurses play a vital role in promoting immunisation uptake and delivering education around healthy relationships, sexual health and contraception. 

2. Supporting children and young people with additional needs 

This high-impact area involves providing tailored support for those with long-term health conditions, disabilities or complex needs. This includes:

• care planning
• working in partnership with families, schools and other professionals to ensure equitable access to education and health services
• ensuring information is accessible for parents who may themselves have additional or complex needs

3. Keeping children and young people safe and well

This high-impact area involves:

• promoting mental and emotional wellbeing and resilience
• identifying local contextual safeguarding concerns
• supporting children and young people affected by bullying, exploitation or violence

School nurses contribute to early intervention and protection for vulnerable groups, including children in care, young carers, and those experiencing trauma or adversity through parental substance or domestic abuse. 

4. Making transitions 

This high-impact area involves supporting children and young people through prominent life transitions, such as:

• starting school
• moving to secondary education
• starting puberty
• preparing for adulthood

School nurses provide health advice, emotional support, and early identification and intervention. This helps young people navigate change and build the skills needed for independent, healthy living.

The importance of the high-impact areas

Children’s development is shaped by a wide range of factors, including:

• parental mental health
• secure relationships
• access to services
• poverty
• community resources

Health visitors and school nurses are uniquely positioned to assess and identify physical, mental and emotional issues, and provide early, co-ordinated and collaborative interventions. This ensures every child is seen, supported and given the opportunity to thrive.

The importance of the high-impact areas extends beyond individual families. When children are supported to reach a good level of development (GLD) by age 5, they are more likely to succeed in school, maintain good health and thrive.

Conversely, when needs in early childhood go unmet, the consequences can be long lasting and far reaching. Children may face:

• poor educational outcomes
• increased risk of mental health difficulties
• greater reliance on social care and other public services

By promoting resilience and narrowing inequalities, the high-impact areas play a vital role in reducing health disparities and fostering a healthier, fairer society. This proactive approach not only improves individual and community wellbeing, but also helps to reduce long-term costs across health, education and social care systems. 

The high-impact areas reinforce the value of integrated working. Health visiting and school nursing teams do not operate in isolation - they collaborate with:

• primary care and NHS community services
• early years providers
• schools
• local authorities
• voluntary organisations
• social care providers
• specialist services

This multi-agency approach ensures that families receive holistic, co-ordinated support tailored to their unique circumstances. The high-impact areas help to:

• build stronger, more resilient communities
• improve service efficiency
• ensure that public health nursing expertise is used to its fullest potential

By aligning with national priorities and delivering targeted, proportionate support, the high-impact areas directly contribute to the government’s ambition to raise the healthiest generation of children ever. This goal depends on early intervention, equitable access to services, and a co-ordinated approach to child and family wellbeing - all of which are at the heart of the health visiting and school nursing model. 

The role of the public health nursing teams

Health visitors are qualified specialist community public health nurses (SCPHNs) who lead the delivery of the healthy child programme for children aged 0 to 5 years and, along with their teams, are responsible for delivering the 6 health visiting high-impact areas.

School nurses are qualified SCPHNs who lead the healthy child programme for children and young people aged 5 to 19 and, along with their teams, are responsible for delivering the 4 school-aged high-impact areas.

A well structured skill mix model enhances the capacity, flexibility and responsiveness of public health nursing teams. When appropriately delegated and supported, skill mix practitioners (including registered nurses, registered nursing associates and unregistered support staff) make a vital contribution to the delivery of the healthy child programme. This involves such staff contributing: 

• diverse skills and perspectives that enrich service delivery
• relational strengths that help build trusted connections with children, young people and families
• practical insight that enables more targeted and timely interventions
• capacity that allows qualified SCPHNs to focus on leadership, complex assessments and safeguarding
• continuity of care and improved access, particularly in underserved or high-need areas

When targeted support is required, qualified SCPHNs lead the planning of structured intervention and may assign specific elements as delegated tasks to skill mix colleagues. Delegated work should:

• be based on assessed need
• fall within the staff member’s scope of competence
• be delivered under appropriate supervision

While the SCPHN holds overall accountability, delegated work is carried out with considerable autonomy and professional responsibility. All registered practitioners remain accountable for their own actions and omissions in line with the Nursing and Midwifery Council’s Standards of proficiency for registered nurses.

Where practitioners are unregulated, this should be made explicit in service protocols and supervision arrangements. Delegation to unregulated staff must be carefully considered, clearly documented, and supported by robust governance to ensure safe, ethical and effective care. 

The skill mix in health visiting and school nursing teams’ practice is grounded in strengths-based, culturally sensitive, trauma-informed and relationship-centred approaches. This ensures that families are supported with compassion, continuity and respect for their lived experience.

Health visiting and school nursing teams work in close partnership with a wide range of services to deliver integrated, preventative care that helps every child thrive. These collaborative relationships are essential to delivering joined-up care that is responsive to local needs, and supports improved outcomes for all children, young people and families. 

The 4 levels of service offer 

Health visiting and school nursing teams operate across 4 levels of service: community, universal, targeted and specialist.

Community level

At the community level, practitioners contribute to public health by engaging in population-wide approaches that promote health and safe environments, and reduce health inequalities.

Universal level

At universal level, practitioners deliver the core healthy child programme to all families, ensuring accessible information is shared to promote physical, emotional and mental health and wellbeing, as well as national public health campaigns.

Practitioners signpost and refer to other services, liaising with multi-agency colleagues, and consider escalation to targeted or specialist level of support in line with assessed need.

Targeted level

At the targeted level, practitioners deliver additional support, based on an assessment identifying specific needs, to reduce escalation of concerns, build resilience and empower families through strengths-based and trauma-informed approaches.

Targeted support can be structured in 2 ways:

• targeted selective support is offered proactively to families who are at higher risk of poor outcomes due to known vulnerabilities, such as:
  • young parental age
  • social isolation
  • housing instability
  • a history of trauma
• targeted indicated support is provided when a specific concern has been identified - for example:
  • a sensory impairment
  • delayed speech and language
  • mild to moderate mental health difficulties in a young person (and/or parent)
  • atypical attachment and bonding
  • the social impact of neurodiversity

During targeted support, health visitors identify and support high-risk groups, including:

• families experiencing housing insecurity, such as those seeking asylum, living in temporary accommodation or hostels, or experiencing homelessness
• care-experienced families, including young parents who have been in care or are leaving care
• families experiencing domestic abuse or substance misuse, where home safety and parenting capacity may be compromised
• families experiencing parental physical or mental ill health, disability and/or learning needs
• families with diverse cultural backgrounds or language barriers
• families with complex or multiple needs, where several risk factors intersect

All targeted interventions should be tailored to the family’s circumstances and may be delivered (sometimes jointly with partner agencies) in home visits, clinics or community settings.

Practitioners should be mindful that not all families are able or willing to attend group-based services, and home-based support may be essential to ensure equitable access.

Specialist level

At the specialist level, practitioners deliver substantial interventions for families requiring intensive or more complex care, based on ongoing assessment and analysis of greater need.

Support at this level is often more comprehensive and longer term, and may include, but is not limited to:

• safeguarding concerns
• support for those with significant health vulnerabilities and/or complex developmental needs, including children with SEND
• support for care-experienced or looked-after children
• families who require longer-term, multi-agency support beyond the scope of time-bound targeted interventions

Specialist-level support also aims to strengthen relational safety and caregiving capacity, particularly where families are experiencing trauma, adversity or complex vulnerabilities. Practitioners should work in a trauma-informed way, promoting trust, emotional containment and reflective engagement.

The principle of proportionate universalism

This tiered model reflects the principle of proportionate universalism, ensuring that all families receive essential support, with enhanced help for those facing greater disadvantage. This enables all families to receive a core universal service offer, while those with additional or complex needs are offered personalised targeted or specialist interventions, helping to reduce inequalities and improve outcomes.

The 4-level service offer is used to:

• meet diverse needs effectively and equitably
• intervene early, preventing issues from escalating
• ensure resources are focused where they will have the greatest impact
• enable joined-up working and information sharing across services, supporting seamless pathways of care

The tiered approach is fully aligned with the refreshed healthy child programme, 10 Year Health Plan for England: fit for the future (referred to throughout this guidance as the ‘10 Year Health Plan’) and the government’s commitment to Giving every child the best start in life and keeping children safe, with Best Start Family Hubs providing a central access point for services.

Measuring success: demonstrating impact and improving outcomes 

Delivering meaningful change through the high-impact areas requires evidence of impact, not just activity. For health visiting and school nursing teams, measuring success is essential for the following purposes: 

• supporting equitable outcomes for children, young people and families
• demonstrating value to commissioners and stakeholders
• driving continuous improvement in service delivery
• strengthening the case for investment in prevention and early intervention

To fully understand and evidence impact, services should capture not just what they do, but what difference it makes - for individuals, communities and the wider system. 

Impact and outcomes 

Public health nursing contributes to a wide range of outcomes, shaped by multiple influences over time. It is important to measure both short-term outputs (such as assessments completed and referrals made) and long-term outcomes (such as emotional wellbeing, school readiness and reduced health inequalities). 

Examples of output and outcome indicators include the following. 

For ages 0 to 5 and health visiting:

• breastfeeding initiation and continuation
• Ages and Stages Questionnaire (ASQ) scores at different time points
• school readiness at age 5 (proportion of children achieving GLD)
• reach and engagement, particularly in regard to underserved families (captured by measurements of additional health visitor contacts)

For ages 5 to 19 and school nursing: 

• emotional wellbeing indicators
• school attendance and engagement
• access to social, emotional or mental health support
• uptake of immunisations and routine checks
• reduced hospital attendance for preventable conditions (such as dental extractions)
• lower obesity rates
• reduction in risk-taking behaviours (such as substance use or unprotected sex)
• improved outcomes for children and young people with SEND

Services should also draw on local intelligence and public health data sources (such as Fingertips and joint strategic needs assessments) to monitor population-level trends and inform strategic planning. 

Data-informed decision making 

Robust measurement is not just about proving impact - it is about learning and adapting. Embedding a culture of data-informed practice helps teams: 

• identify gaps and unmet needs in real time
• tailor interventions to local population profiles
• monitor progress against strategic priorities (such as Best Start for Life, the Families First Partnership programme and SEND improvement plans)
• support joint planning, commissioning and workforce development

Tools such as logic models, theories of change and performance dashboards enable services to map how inputs lead to outcomes, making value visible and actionable for stakeholders. 

Effective and equitable service delivery 

Evaluating service delivery ensures consistency, equity and responsiveness for diverse populations. Evaluation includes assessing whether services are accessible, inclusive and responsive to the needs of diverse communities. 

Primary indicators may include the following: 

• completion of universal ages 0 to 5 health and development reviews, which are to be carried out at 5 specified stages under The Local Authority (Public Health, Health and Wellbeing Boards and Health Scrutiny) Regulations 2013 (such as following birth and at 6 to 8 weeks old), and other additional non-statutory reviews
• school entry reviews and ages 5 to 19 health needs assessments
• timely and appropriate interventions based on assessed need
• use of validated tools and care pathways (such as the ASQ, Strengths and Difficulties Questionnaire (SDQ) and Early Language Identification Measure (ELIM))
• equity of access - disaggregated by deprivation, ethnicity, language, disability and other protected characteristics
• early identification and targeted support for vulnerabilities, including but not limited to the following:
  • housing insecurity or poor housing that may impact child health
  • poverty or financial hardship
  • poor parental mental or physical health
  • substance misuse
  • learning disabilities and other types of neurodiversity.
  • limited networks of support
  • lived experience of the care system (care leavers are eligible for healthy child programme support up to the age of 25)
  • young parenthood
  • exposure to neglect, emotional, physical or sexual abuse or other forms of harm, whether inside or outside the home and/or online
  • domestic abuse
  • presence of unknown adults in the home, particularly where risk factors are unclear or unassessed
  • a history of interactions with the criminal justice system
  • children with a parent involved in the criminal justice system
  • a record of sustained absence from school (even if due to suspension or exclusion)
  • those with current or historic experience of children’s social care, including children with a social worker and those subject to child in need assessments and/or enquiries under section 47 of the Children Act 1989 and/or child protection plans
  • those with SEND or complex health needs, or undergoing palliative or end-of-life care
  • a tendency (historic or ongoing) to go missing
  • a risk of exploitation, child sexual exploitation or modern slavery

Triangulating service data with workforce feedback, audit and reflective practice ensures quality and helps identify variation in delivery.

Continuous quality improvement (CQI) 

Measurement should be part of a learning cycle - not a tick-box exercise. Applying CQI principles helps teams evolve with changing needs by: 

• using Plan-Do-Study-Act (PDSA) cycles to test and refine approaches
• promoting peer learning and reflective practice to share what works
• benchmarking performance across regions to reduce unwarranted variation

This approach encourages innovation while maintaining accountability to families and the wider system. 

Workforce impact and capability 

A competent, confident and well supported workforce is essential to delivering high-quality, equitable care. Informative metrics include the following: 

• practitioner confidence and skill development
• access to reflective supervision and continuing professional development
• workforce wellbeing and retention indicators
• links between practitioner capability and service outcomes

Workforce data should be monitored alongside service impact measures to demonstrate the case for investment and sustainability. 

Experience and engagement 

According to Fair Society, Healthy Lives: the Marmot Review - a strategic review of health inequalities in England post-2010, understanding the lived experience of children, young people and families is vital for improving services and building trust and understanding of how they experience services within the system.

Experience data should be gathered routinely and used to shape both operational delivery and strategic development. Approaches may include the following: 

• NHS Friends and Family Test or bespoke satisfaction surveys
• co-production activities (such as parent and carer panels or youth voice forums)
• real-time feedback through digital platforms or drop-in sessions
• engagement with under-represented communities to ensure cultural relevance and accessibility
• reflective supervision and practitioner feedback to support workforce wellbeing and effectiveness

Involving families in service design and improvement fosters shared ownership and ensures services are responsive to real-world needs.