'Facing the future': the government's real agenda for health visitors.
Medical personnel (Practice)
Medical personnel (Laws, regulations and rules)
Medical personnel (Reports)
Meulen, Ruud ter
|Publication:||Name: Community Practitioner Publisher: Ten Alps Publishing Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2008 Ten Alps Publishing ISSN: 1462-2815|
|Issue:||Date: Nov, 2008 Source Volume: 81 Source Issue: 11|
|Topic:||Event Code: 200 Management dynamics; 930 Government regulation; 940 Government regulation (cont); 980 Legal issues & crime Advertising Code: 94 Legal/Government Regulation Computer Subject: Government regulation|
|Product:||Product Code: 8010000 Medical Personnel NAICS Code: 62 Health Care and Social Assistance SIC Code: 8000 HEALTH SERVICES|
|Geographic:||Geographic Scope: United Kingdom; England Geographic Code: 4EUUK United Kingdom; 4EUUE England|
This paper draws on the ideas of Foucault to analyse the government's recent review of the role of health visitors in England, 'Facing the future'. It outlines the Foucauldian concepts of discourse, knowledge and power and examines the review document following an accepted six-step process for the analysis of discourse. The analysis considers how 'Facing the future' constructs the present and future roles of health visitors, and elucidates the 'regimes of truth' that operate in official policy. It highlights the way in which the document proposes a shift away from health visitors' traditional emphasis on building supportive relationships with clients, toward a stronger emphasis on outcome-oriented service provision by multi-skilled teams. In line with contemporary public health discourse, 'Facing the future' also reinforces the future role of health visitors as being one that supports individuals to make lifestyle changes to improve health rather than addressing wider environmental and social determinants.
Although 'Facing the future' purports to reflect a consultative review and to encourage debate within the health visiting profession, its form is more akin to a promotional document to implement government proposals for social change.
Health visiting, 'Facing the future', discourse analysis, Foucault
* Foucauldian concepts of discourse, power and knowledge were used to analyse the construction of the health visitor's role within the Facing the future review
* Facing the future constructs a highly negative view of the current role of health visitors, and presents a discursively persuasive case for a transition to a more positive future role
* It emphasises the importance of evidence-based, cost-effective service provision, but reflects unrealistic expectations that all aspects of health visitors' interactions can be measured
* It downplays the importance of health visitors developing trusting relationships with clients
* Although Facing the future purports to be based on broad consultation, its form is more akin to a promotional document to implement government proposals for social change
In November 2006, the secretary of state for health commissioned a review of the future role of health visitors in England. Following consultation with over 1000 health visitors, national and local leaders, and other stakeholders such as parenting organisations, the review report Facing the future (1) was published in June 2007. It proposed significant changes to health visitors' roles that warrant careful analysis.
The analysis reported here was conducted as part of a broader investigation of the ethical issues arising from changes to health visitor roles. It draws on Foucauldian concepts of discourse, power and knowledge, which have been used fruitfully in the past to analyse aspects of the health visitor's role. (2-7)
In order to understand the process of Foucauldian discourse analysis, it is important to consider Foucault's concepts of discourse, power and knowledge.
By 'discourse', Foucault meant 'a group of statements which provide a language for talking about--a way of representing the knowledge about--a particular topic at a particular historical moment ...' (p72). (8) Discourse influences how ideas are put into practice. It is used to regulate or control the conduct of individuals or to meet the objectives of particular institutions or organisations. (9) Foucauldian discourse analysts assume that there is not only one version of the world that can be articulated and studied, but numerous versions that are constructed through discourse.
Foucault was interested in how power functioned within society. He argued that power is not simply enforced through the top-down imposition of laws and rules (such as from a sovereign or the state), and it is not only deployed negatively through repressing that which it seeks to control. Rather, power relations associated with knowledge permeate all levels of society, and can be productive as well as repressive.
Foucault argued that knowledge is always a form of power. Our understanding of a topic has a bearing on how we regulate and control that topic. For Foucault, knowledge does not operate in isolation but is applied in specific situations, historical contexts and institutional regimes. The truth of knowledge should not be understood in an absolute sense as a truth that remains so whatever the period, setting or context. The discursive formations of particular contexts instead sustain 'regimes of truth'. (8)
A copy of Facing the future was obtained from the website of the chief nursing officer for England. (10) It was analysed by following the procedural guidelines for the analysis of discourse as outlined by Willig (11) (see Table 1) in order to uncover the unspoken and unstated assumptions implicit within it. (12)
Results of the analysis
Discursive constructions: the present and future roles of health visitors
Facing the future describes the health visitor's role as being 'at a crossroads' (p30). Discursive constructions of the role are achieved through numerous references to a 'present role' and a 'future role', which are ascribed distinctive characteristics. The present role is constructed in negative terms. Health visiting is said to have 'lost its focus'. The profession is described as being 'lost and under pressure' (p9) as a result of there being 'too many foci for anyone ... to be able to define what health visiting was about and what health visitors should be doing' (p4). Those responsible for educating health visitors and commissioning their services are also said to have 'lost their focus' (p4), resulting in 'a lack of consistency in the services offered to families and a lack of clarity about the role' (p14). Not surprisingly, given this, parents too are described as 'concerned about access and confused about what to expect from the service' (p14).
In contrast, the future role is constructed far more positively, and the review positions itself as aiming to 'sharpen, clarify and revitalise' the health visitor's role (p4). Within this new role, services provided would be 'planned and systematic' (p29). The review also aims to 'set out a vision for the future' with 'clarity and direction about the current and future role of health visitors' (p9) and 'describe a role ... that focuses on the needs of children and families, and on what commissioners, providers and the health visiting profession need to do to implement that role' (p10).
Discourses: the future role and positive progress
Wider discourses govern what is acceptable to say or think about the role of the health visitor at this particular time. Facing the future draws on the discourses of scientific progress, of education 'fit for purpose' and of commissioning.
Firstly, there is the 'scientific' discourse that regards quantitative scientific knowledge as being of prime importance in the future role as 'developments in science and technology aim to change what is possible and how services are delivered' (p11). There is reference to 'emerging knowledge and evidence' and 'a greater emphasis on evidence-based programmes with measurable outcomes' (p11). In the future role, health visitors should translate 'evidence into practice' (p7) and 'deliver evidence-based services' (p15) that focus on 'delivering outcomes' (p29).
With regard to discourses related to 'education and training', the review identified that 'health visitors' knowledge needs updating', that there are concerns about 'reductions in the numbers of health visitors being trained', 'a mismatch between training and service requirements' and 'a loss of leadership' (p14). In contrast, education and training for the future role aims to 'develop a competent and flexible workforce, update career pathways, prepare nurses to lead in a changed health system, and modernise the image of nursing' (p9). This will be achieved by moving from the standard 52-week course to 'modular learning, flexible curriculum' and training, and equipping all health visitors to do the job on the ground (p29).
The review states that 'parents, commissioners, GPs, local authorities, policy makers and the profession all seem to have different expectations of the role and what services should be provided' (p14). In contrast, the future role is described as one that 'primary care trusts (PCTs) and practice-based commissioners will commission' (p5).
Action orientation: preparing for change
The wider context within which the roles are constructed includes societal changes such as 'greater social, cultural, racial and geographical diversity', 'an ageing population', 'an increase in long-term conditions'; 'inequalities', and 'developments in science and technology' (p11). The review assumes that action is needed to ensure the present workforce--made up of older, largely white, female health visitors--will be replaced by a younger workforce with an ethnic and gender mix that reflects diversity within the population and facilitates engagement with fathers as well as mothers (p29).
Wider government reforms that are 'aiming to change the way that services are provided, putting patients, users, and the public first' (p11) are also contextually relevant. In the future role, it is anticipated that present nine-to-five working hours will be replaced by a more flexible working pattern in order to meet public needs and demands.
The need for change is a recurrent theme, and the review contains an explicit list of 'coming from' and 'going towards' statements (p29). While acknowledging that 'for many generations, health visitors have been a valued resource and ... a positive influence on the health and wellbeing of families' (p9), the document reiterates the need to describe a new role to ensure that health visitors are 'fit for the future' (p9) and 'recognise the challenges facing the profession' (p16). The need for change is also implicit in the statement that 'it is not simply a question of having more health visitors doing the same work' (p5), but rather that 'there is a need to focus the role and use high-level skills more effectively' (p14). The challenge to achieving this change is highlighted by stating that 'health visitors have an image of being defensive and resistant to change' (p14).
Positionings: health visitors' identities
Two distinct subject positions for health visitors are defined in the present and future roles. The review anticipates that health visitors will be reformed from their current 'unfocused' position into occupying a 'sharper, clarified and revitalised' role with the skills and knowledge to lead 'well trained and competent teams' (p31). The subject position offered to health visitors by the new construction is that of 'experts', with skills and knowledge that are applied in a focused way to the areas where they can make the most impact. This entails a move away from the 'cradle-to-grave' model of the past toward a focus on young children and families (p29).
Health visitors are encouraged to see themselves less as individuals with their own caseloads, and more as 'team players' and 'community leaders'. They are to be positioned as members of multi-skilled teams that include nurses, nursery nurses, parenting practitioners, health trainers and midwives, and they are among those who are professionally accountable for delivering a commissioned service.
Practice: public health and nursing
The review recommends that health visitors should focus on 'early intervention, prevention and health promotion for young children and families' (p6). Health visitors will play a lead role in:
* Preventing social exclusion in children and families
* Reducing inequalities
* Tackling key public health priorities obesity, smoking, alcohol, drugs and accident prevention
* Promoting infant, child and family mental health
* Supporting the capacity for better parenting (p19).
Two primary roles are identified--leading and delivering the Child Health Promotion Programme (13) (CHPP) and delivering intensive programmes for the most vulnerable children and families.
Health visitors contributing to the review identified that key areas of public health practice were not being realised, due to resource issues and the domination of 'short-term acute commissioning decisions' (p16). 'However, in keeping with devolved responsibility and local decision-making' (p9), the review 'does not tell the service what to do, neither does it make recommendations on numbers and resources. Rather, it describes a role for the future ... and what commissioners, providers and the health visiting profession itself need to do to implement that role' (p10). By stating its aim of 'supporting those leaders and practitioners ... who are forging ahead and developing a profession that will have a confident, relevant and sustainable future' (p10), the document puts responsibility for making many of these changes firmly into the hands of practitioners. It thus distances government from any potential problems.
Subjectivity: what will it feel like to be a health visitor?
In the construct of the present role, the health visitor's subjective experience is likened to being 'pulled in a dozen different directions, everyone wanting something different from us', 'a jack of all trades' (p15), with the result 'that the important and often unseen work that health visitors are doing has gone unrecognised and therefore undervalued' (p4). That some health visitors held a positive subjective view, clearly stating that they felt 'proud of what we are doing, knowing that we are making a difference' (p13) and maintained a sense of 'opportunity and optimism' (p14), is laid aside quickly. The review assumes that negative subjective experiences will be replaced when working in a role that delivers 'high-quality, universal services against clear service specifications and to agreed outcome measures' (p15).
Discourse analysis gives great power to analysts to impose meanings on another's text, (12) and it is acknowledged that in the following discussion the authors' own arguments are also discursively constructed.
The highly contrasting constructions of the health visitor's role developed in Facing the future are powerful. They provide certain ways of seeing present and future roles, and serve to convince of the need for change. That over 1000 health visitors were consulted is utilised to persuade the reader of the validity of the document as representing what most health visitors and stakeholders think. However, research by the Family and Parenting Institute (14) found huge support for the present health visiting role. Although Facing the future constantly alludes to the need for clarity and direction, it leaves many recommendations about the future role open to wide interpretation.
The way in which Facing the future locates the role of the health visitor within wider discourses--such as those emphasising the importance of outcomes--also serves to convince readers of the need for change. While there is likely to be a broad consensus that health visiting practice should be effective and open to scrutiny, outcome measurement is problematic because many health visiting outcomes are likely to be long term, such as those related to obesity and mental health. (15) Facing the future incorporates implicit and unrealistic assumptions about the ability of health visitors to measure professional interventions and their effects, and its recommendations threaten to undermine professional autonomy by reducing practice to a series of procedures driven by the need to meet reporting and recording requirements. (16) Munroe (17) argues that these government targets and performance indicators place too much emphasis on the needs of society for well-educated, healthy citizens rather than on the needs of the individual child.
Commissioning discourses have become increasingly prominent with the continued move toward a healthcare market. Facing the future envisages that PCTs and practice-based commissioners will commission the future health visiting role, but does not say how this will happen. In their response, the government state that 'most of the recommendations ... are for the service and the profession to take forward. It is for local commissioners ... to decide how services should be provided, resourced and delivered ...' (p7). (18) However, Unite/CPHVA believe this is dependent upon commissioners understanding the impact that a properly resourced health visiting service can make to improving the health and wellbeing of all families and communities. (15) While the CHPP is key to delivering the Public Service Agreement (19) for improving children's health and well-being and contributing toward the goal of Every child matters, (20) it lacks government enforcement--outcomes will only be met if PCTs implement the programme. Health visitors need to interact critically with the policy environment, and also seek to influence decisions regarding service provision and commissioning of the programme. (21) The 'modernisation' agenda is typified by a move toward 'partnerships' between government, business and the voluntary sector. Commissioners could contract health visiting services from these new providers, thus reinforcing and extending the government policy of a mixed economy in healthcare provision. It remains to be seen whether this discourse of devolved responsibility, partnership and a mixed healthcare economy will bring opportunities for innovative practice, or whether it will merely facilitate the incorporation of business interests and an emphasis on cost-effectiveness into the management of services.
By positioning itself as the commissioner of the review that underpinned the production of a document exposing inadequacies in the health visiting role and outlining plans for a modernised role, the government seems to conveniently escape any responsibility for how the situation arose in the first place. This must be viewed in the context of the government's requirement for PCTs to balance their financial accounts, which led to a 40% reduction in the number of health visitors being trained in 2007. (22)
While the government repeatedly advertises 'people-centred' policies, the review outlines a move away from a health visitor service where the establishment of a professional health visitor-client relationship is paramount, toward a child health service in which different aspects are delivered by different team-members. Although it will be important that such teams comprise an appropriate level of skill mix, the review fails to identify the basis on which skill-mix decisions should be made.
A key area of practice identified in the future public health role is supporting people to make changes to bring about health improvement. By emphasising lifestyle change, contemporary public health discourses are moving responsibility for public health issues away from the state and onto individuals. However, health visitors also need to support collective, multi-agency public health approaches that address wider environmental and social determinants of health.
Foucault argued that it is as important to identify what discourse 'rules out' in relation to a topic as it is to identify what is 'ruled in'. The Unite/CPHVA response to the review identified that the review lacks any reference to the 'principles of health visiting' upon which the profession has developed. (15) These have recently been revisited and updated (23) and should still underpin services. Also absent from the review is the role of health visitors in supporting families who have children with special needs, or the challenges of working with families from a multitude of ethnic backgrounds. (15)
This analysis has mapped out the discursive worlds that the government has constructed for health visitors to inhabit, and it has traced the possible subject positions afforded by these.
The present and future roles of health visitors constructed within Facing the future operate within the 'regimes of truth' or official policy of this particular period. There are several grounds for concern about this policy discourse. First, the importance of building trusting relationships with clients in order to provide help and support is downplayed, and replaced with an unrealistic emphasis on evidence-based and measurably cost-effective service provision. This could prove detrimental to outcomes in the long term as health visiting concerns may not be readily measurable, and the establishment of a non-judgemental and listening relationship that allows flexibility and trust on both sides is central to achieving legitimacy for health visitor interactions, which must be established before any meaningful work can take place. (2) Second, the government's intended control over individual lifestyles is strengthened, as the discourse reinforces efforts to change individuals' behaviour and to engage healthcare professionals more explicitly and intensively in this.
A critical factor in producing policy and institutional change is managing people's perceptions, shaping their viewpoints and promoting new discourses. It could be argued that, although Facing the future was intended to report on a consultative review that set out to encourage debate within the health visiting profession, it has become a promotional document to implement government proposals for social change, by way of top-down control of individual lifestyle and the implementation of economic criteria and commercial initiatives. As the social construction of reality through discourse is characterised by change and transformation, new discourses will continue to appear, bringing new discursive formations with the power and authority to regulate social practices in new ways, and in turn produce new conceptions of the role of the health visitor.
The authors would like to thank North Bristol NHS Trust occupational therapist Lucy Blenkiron for helpful discussions while conducting the discourse analysis.
(1) Department of Health. Facing the future: a review of the role of health visitors. London: Stationery Office, 2007.
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(5) Dingwall R, Robinson K. Policing the family? Health visiting and the public surveillance of private behaviour. In: Beattie A, Gott M, Jones L, Sidell, M (Eds.). Health and wellbeing: a reader. Milton Keynes: Open University, 1993.
(6) Heritage J, Lindstrom A. Motherhood, medicine and morality: scenes from a medical encounter. Research on Language and Social Interaction, 1998; 31(3/4): 397-438.
(7) Peckover S. Supporting and policing mothers: an analysis of the disciplinary practices of health visiting. Journal of Advanced Nursing, 2002; 38(4): 369-77.
(8) Hall S. Foucault: power, knowledge and discourse. In: Wetherell M, Taylor S, Yates S (Eds.). Discourse theory and practice: a reader. London: Sage, 2001.
(9) Fairclough N. The discourse of New Labour: critical discourse analysis. In: Wetherell M, Taylor S, Yates S (Eds.). Discourse as data: a guide for analysis. London: Sage, 2001.
(10) Department of Health. Chief nursing officer. London: Department of Health, 2008. Available at: www.dh.gov.uk/cno (accessed 30 September 2008).
(11) Willig C. Introducing qualitative research in psychology. Maidenhead: Open University, 2001.
(12) Cheek J. At the margins? Discourse analysis and qualitative research. Qualitative Health Research, 2004; 14(8): 1140-50.
(13) Department of Health. Child health promotion programme. London: Stationery Office, 2008.
(14) Family and Parenting Institute. Health visitors: an endangered species. London: Family and Parenting Institute, 2007.
(15) Unite/CPHVA. Unite/CPHVA response to 'Facing the future: a review of the role of health visitors'. London: Unite/CPHVA, 2007.
(16) Whiteford G. Autonomy, accountability, and professional practice: contemporary issues and challenges. NZ Journal of Occupational Therapy, 2007; 54(1): 11-4.
(17) Munro E. Confidentiality in a preventive child welfare system. Ethics and Social Welfare, 2007; 1(1): 41-55.
(18) Department of Health. The government response to 'Facing the future: a review of the role of health visitors'. London: Stationery Office, 2007.
(19) Department of Health. Public Service Agreement delivery agreement 12: improve the health and wellbeing of children and young people and maternity services. London: Stationery Office, 2004.
(20) Department of Education and Skills. Every child matters. Norwich: Stationery Office, 2003.
(21) Adams C, Newland R. What the CHPP means. Community Practitioner, 2008; 81(6): 36-7.
(22) Amicus/CPHVA. 40% axe in health visitor training places 'sabotages' government public health goals: ministers told to stop acting like Pontius Pilate (press release 7 February). London: Amicus/CPHVA, 2007.
(23) Cowley S, Frost M. The principles of health visiting: opening the doors to public health practice in the 21st century. London: Amicus/CPHVA, 2006.
Julie Greenway MA, BSc, RGN, RHV
Medical Research Council (MRC) Health Services Research Collaboration PhD student, University of Bristol
Paul Dieppe FFPH, FRCP, MD, BSc
MRC senior clinical scientist and professor of musculoskeletal science, Nuffield Department of Orthopaedic Surgery,
University of Oxford
Vikki Entwistle PhD, MSc, MA
Professor of values in health care, Social Dimensions of Health Institute, Universities of Dundee and St Andrews
Ruud ter Meulen PhD
Professor of ethics in medicine, University of Bristol
Table 1. Procedural guidelines for the analysis of discourse Stage Method Discursive The document was analysed and specific references constructions to the role of the health visitor were highlighted in order to identify the different ways in which it was constructed in the text Discourses Wider discourses were identified from the document and an analysis carried out of the ways in which they were used in the different constructions of the roles Action The discursive contexts within which the orientation different constructions of the health visitor's role were deployed were examined in order to gain a clearer understanding of what the various constructions achieved Positioning The subject positions constructed for health visitors within the document were considered Practice The document was systematically explored to identify ways in which the discursive constructions and the subject positions contained within them could affect health visitors' opportunities for practice Subjectivity Specific references to what could be felt, thought or experienced from within the subject positions were highlighted in order to trace the consequences for health visitors' subjective experience
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