How's the baby doing?

In recent years the role of a health visitor has shifted from providing a cradle-to-grave service to caring for small children. Amy McLellan looks at a career that gives valuable support to families in need

As any new parent will tell you, having a baby changes your life in significant and sometimes unexpected ways. There are the hormones, the sleep deprivation, the financial pressures and the constant worry - is my baby normal? This is where the health visitor service comes into its own.

A health visitor is a registered nurse, with at least two years of nursing practice under her belt (the vast majority of health visitors are women), plus a further year's specialist degree-level training in public health issues. Although the service is meant to be cradle-to-grave, in recent years the focus has shifted to families with children ranging from newborn to five years old.

A health visitor comes to your home, usually within 10 to 14 days of the birth, to check how the family is coping with the new arrival. Further visits will be made over the course of the next five years, and the frequency will depend on the needs of the family and the resources of the local NHS. The health visitor will check the child's development and, if necessary, refer the family to specialists, such as a speech therapist or a physiotherapist.

Health visitors also screen for signs of post-natal depression; advise on nutrition, breast-feeding and immunisation; and have a role to play in child protection, reporting any early warning signs to the appropriate authorities.

"Because we see a family at home, we have a lot of insight into what goes on behind closed doors," says Obi Amadi, lead professional officer of the Community Practitioners' and Health Visitors' Association, the third-largest nursing union in the UK. "Someone can appear to be in control in the street but be living in complete chaos at home."

Health visitors can help bring some order and stability to that chaos. They help families with parenting skills, advise on local support networks and make sure parents know their employment and benefits rights. This can often mean putting parents in touch with NGOs and charities, often scanning the internet or their network of contacts to find the right help for a family in need.

Health visitors will contact the local council about accommodation problems, sometimes writing letters on behalf of the family. Visitors will help them to access specialist services, such as trained counsellors or treatment centres if, for example, someone is struggling with bereavement or addiction.

It's a very holistic approach to healthcare that embraces the whole family's health and wellbeing in the interests of the young child - one that has an underlying philosophy of prevention rather than cure.

"We're there to make sure that by the time the child reaches five and you hand over to the school nurse, he or she has reached their optimum in terms of development, growth and health," Amadi says. "It's very proactive. We're there to help before any problems develop."

This preventative approach appeals to many healthcare professionals. Denise Stenner, a lead health visitor in north Dorset, signed up for the health visitor training for this very reason.

"I'd always been very keen on health promotion and preventative medicine, and keeping healthy people healthy rather than just seeing people once they are ill," she says.

It's impossible to be bored in this job. Tracey Holland, a health visitor with the Sutton and Merton Primary Care Trust in Surrey, picks out a random day from her diary - it's chock full with meetings about children on the child protection register, followed by a series of home visits to families with newborns, women with post-natal depression and parents whose children have complex special needs. "There's no such thing as a typical day," Holland says. "It's very varied, and that's part of the attraction."

Unlike hospital nursing, it's a role that offers real autonomy and independence. Health visitors manage their own workloads, can prescribe from a limited formulary and make direct referrals to specialists.

There's also the opportunity to pursue special interests that suit the needs of the community: setting up a sleep clinic, for example, providing extra support for mothers who want to breastfeed, or running a campaign to highlight testicular cancer.

This, however, is a service under pressure. When a primary care trust or other NHS employer is looking at spending priorities, the health visitor service is often seen as a soft option. The failure to recruit fresh blood into a profession with an aging workforce could deal a devastating blow to an already stretched service, and some health visitors are concerned that vulnerable families could slip through the net.

One health visitor working in Hackney, east London, who asked not to be named, says that stress levels in the job are increasing. "When you come in on a Monday morning, you may have 50 new-birth contacts on your desk, plus two clinic sessions to run, two visits to social services for case conferences, phone calls to make about housing, plus team and development meetings, and all the paperwork," she says. "There just aren't enough hours in the day. The worry is always on your mind that someone gets missed."

So the job is stressful - and stress-related absences are adding to the pressures. It takes a special person to be able to cope with the work load and the responsibility. "You always have to be on the ball, you have to spot things and to work out what's going on in a family," says Millie Quayfon, a health visitor in Streatham, south London. "There are a lot of child protection issues, which are stressful to deal with."

Despite the pressures, most health visitors are proud of the work they do and the difference they make to people's lives. Often the changes seem small - spotting a squint, or helping an overwrought mother get her toddler to sleep through the night - but the impact can be long-lasting.

"We're very privileged because we influence how children grow up. The advice we give on diet and exercise are lessons that they take with them through life," says Denise Stenner. "The downside is that we often don't get to see any immediate results because the benefits are long term."

Perhaps most important is that this is a universal service that reaches the most vulnerable families in our society. "We try to access every single family, even in the most difficult or violent areas," says Obi Amadi. "It might be a no-go area for the postman, but the health visitor still goes in."

The lowdown

How much will I earn?

Pay starts at about £24,000 outside London, while more experienced health visitors can expect to earn between £27,000 and £32,000. NHS London allowances apply.

What are the hours?

Most visitors work Mondays to Fridays, 9am to 5pm.

Qualifications?

You'll need to be a registered nurse with at least two years' practice. You must do another year's training, half in the classroom, half supervised practice. You have to secure a course place and sponsorship from a community health trust.

Any additional skills?

You need good communication skills, must be comfortable visiting people in their homes, be organised and able to prioritise a heavy workload. Most jobs require you to drive.

Useful contacts

The Community Practitioners' & Health Visitors' Association ( www.msfcphva.org); NHS Careers ( www.nhscareers.nhs.uk); Royal College of Nursing ( www.rcn.org.uk)

Once the midwife's work is done, the health visitor takes over

'You have to work on your own initiative'

Helen Kelly is a health visitor with the Solihull Primary Care Trust in the West Midlands

"I work from a clinic attached to a GP's practice, and we do a mix of clinic work, where parents can just drop in and ask about any issues they may have, and home visits to families.

Our work is mainly with families who have children under five, and we take over once the midwife has discharged them. We work with the family and help them with any problems they may have. We can help them or put them in touch with specialists, such as child psychologists, if there are any problems around feeding, sleeping or toileting, or of there are any behavioural issues. We also screen for post-natal depression and provide support for parents who are finding it difficult. It is a big transition, particularly for first- time parents, and most people are glad to see us.

There's a lot of paperwork, which can be time-consuming. It's up to you to manage your diary and make sure you do your paperwork daily to keep your records up to date. You have to be able to work on your own initiative. I enjoy the work, and would recommend it to other nurses because it's autonomous and not as restrictive as hospital nursing." A McL