The State of Health Visiting in England: Workforce Composition, Caseloads and Service Delivery

Health visiting is England's universal home visiting programme for families with children under five and a key pillar of early intervention policy. Since the 2015 devolution of commissioning to Local Authorities (LAs), the service has faced sustained financial and workforce pressures, yet there is limited systematic evidence on whether resources and delivery have evolved differentially across areas and along the deprivation gradient. Using new Freedom of Information (FOI) data, we estimate how health visiting inputs (spending and workforce) and mandated contact delivery vary in levels and trajectories by baseline deprivation. FOI requests covered 147 English LAs (four pairs submitted joint returns), providing annual 2016-2021 Full-Time Equivalent (FTE) data on Health Visitors (HVs) and Clinical Skill Mix Staff (CSMS), which we link to DHSC Health Visitor Service Delivery Metrics reporting completion of the five mandated 0-5 reviews (New Birth Visits, 6-8 week reviews, 12-month reviews, 2-2.5 year reviews, and 2-2.5 year reviews completed with ASQ-3) and to LA revenue outturn expenditure on mandated and non-mandated 0-5 public health services (real-terms total and per child under five). Between 2016 and 2021, HV FTE fell by around one-fifth while CSMS expanded by roughly one-third, consistent with an overall contraction and a shift toward lower-band staff. To test whether these changes map onto underlying disadvantage, we stratify LAs into tertiles of baseline deprivation using the 2015 Income Deprivation Affecting Children Index (IDACI) and implement a three-part empirical strategy: (i) plotting tertile means over time, (ii) testing within-year cross-sectional differences using parametric and non-parametric methods with pairwise comparisons, and (iii) estimating LA fixed-effects regressions with Year x IDACI interactions under both a flexible year-by-year specification and a parsimonious linear-trend specification to assess differential trajectories. We find persistent cross-sectional gradients in per-child spending that are broadly progressive (more deprived LAs spend more per child on both mandated and non-mandated 0-5 services), while fixed-effects models show little evidence that spending trajectories differ systematically by deprivation. Workforce trends are more uneven: HV FTE declines more slowly and CSMS FTE grows more slowly in more deprived LAs in the linear-trend specification, while per-child HV trajectories show no differential trends. Despite these input differences, completion of mandated contacts is relatively stable across the deprivation gradient; the only consistent differential trend is faster improvement in the 6-8 week review in more deprived areas. Meanwhile, caseload pressure rises, increasing most sharply in the most deprived LAs in the pre-pandemic years, suggesting that completion-based performance measures may mask heterogeneities in service capacity and intensity. Finally, we quantify the resources required to restore recommended caseloads, implying the need for approximately 3,100 additional FTE staff and around 120 million GBP annually (plus training costs).