A Specialist Health Visitor with Homeless Families
13 June 2019 | Debbie Fawcett, Queen's Nurse
Six years ago I successfully interviewed for a specialist health visitor role, working with ‘homeless families’. It was the start of a learning journey that continues to this day.
In our area, families presenting as homeless will be placed wherever there is suitable accommodation and may often be away from social networks and familiar places. The families live in a range of accommodation including a B&B, women’s refuge, a young mother’s accommodation and three privately run units.
Most families live in a self-contained studio flat, with limited storage, play and kitchen facilities. Placements, described as emergency and temporary, can last from weeks to several years before they are offered more permanent accommodation. Adults describe a lack of control and stability that impacts on their emotional wellbeing, decision making and day to day parenting.
The initial contact is the start of the professional relationship as well as an opportunity to assess the family’s current needs, before signposting to local services and support. All families are unique and often complex. Children may have missed developmental checks and have various unmet needs. Parents can disclose a range of issues such as debt, domestic violence, mental health, and drug or alcohol abuse. Some families may not have seen a health visitor for a while due to ‘being lost in the system’, frequent moves, previous poor service or just different priorities.
Having a specialist role has enabled strong multi-agency working with statutory and voluntary agencies, including social care, children centres and local charities. These positive links have improved professional communication and support for families, as well as lots of opportunities for advocacy around homelessness. However, there is no formal notification process, so identifying new arrivals relies on the building manager, who updates me when I visit. I visit these flats in between booked appointments and despite the ‘cold call,’ families are receptive.
I leave a letter if there is no reply and repeat this until someone answers the door. Families make assumptions on how community services work, which can impact on their initial engagement but can easily be addressed when face to face contact is achieved. Many families will retain a GP using an alternative address to avoid embarrassment or to keep links with a familiar area or trusted professional. These families are easily lost to our services.
Often overwhelmed by the homeless situation, I am able to listen and signpost to services. The five mandated health visitor contacts are offered as home visits, by my-self or my colleague. These visits enable us to establish a relationship and provide continuity, which is valued by ourselves and the families. There is no typical day, just as there no typical family – below are just a few of the children I have met.
‘Mohamed’ has lived in a B&B with its own kitchenette, shared bathroom and extremely limited play space since his birth almost three years ago. His mother left an abusive relationship and although well-educated is unable to work as she struggles with the Home Office to secure her rights to remain in the UK. Mother and child are rarely separated, always within view of each other and this may account for Mohamed’s shyness and need to have physical contact with his mother at all times. Mohamed is not eligible for two year funding, so he must wait till he can access three year funding. Other residents move within 12 weeks, so establishing friendships and social support is difficult.
‘Jane’ was referred to me by an outreach family support worker. She had met the family opportunistically and was concerned that Jane was in a highchair or cot on both her visits and her mother appeared emotionally flat. The family was not known despite me having left numerous transfer in letters. Mother described having been placed by her North London housing authority in South London temporary accommodation three years earlier. When placed on the floor Jane could stand, but cannot sit herself down or stand up without support and walked with poor balance. The movement mimicked that of a child cruising around her cot. On discussion, mother reported her elder daughter attended a school in North London and they travel 3-4 hours a day with Jane sitting in a buggy. At home Jane was not allowed to play on the floor due to a mice infestation and the play space was limited by a large number of packing boxes. Mother explained she was unable to afford long term storage but was reluctant to dispose of her belongings, as she would need them when she moved. The family is registered with a North London GP, using a family friend’s address and Jane attended her 12 month check, scoring 60/60 in all areas. North London health visitors had completed Jane’s developmental checks at the clinic, without any knowledge of her actual whereabouts or living conditions, relying on mother’s verbal report.
A birth notification is another way of finding a new family, but can also be a complex visit. The family was waiting rehousing, having been evicted from a privately rented property. ‘Jasmine’ was the youngest of three children, a healthy breastfed baby. It was clear that the eldest child, ‘Alex’ had significant developmental needs, possibly on the autistic spectrum. It was a difficult conversation, but I have learnt that it is essential not to miss an opportunity before a family moves again. Alex had missed his two year check, but had been referred to a health visitor when he attended A&E following an asthma attack. He had been referred to speech therapist and a children centre, but these referrals were now invalidated as the GP had deregistered them once they moved outside the borough. With some encouragement, father registered locally and further referrals were made to a community paediatrician, speech therapy and OT, but before Alex could be offered an assessment, the family was moved to yet another borough. To avoid a further delay, father agreed not to change GP until Alex’s assessments were completed. Due to the impact of homelessness, the family missed opportunities for parenting support and continuity, as well as impacting on the early assessment for Alex.
Homelessness impacts on a family in a multitude of ways, from accessing health, education and other services in a timely way to the less obvious effects. When circumstances change, such as a households address, benefits need to be updated, triggering a delay in payments, increases financial demands (removal costs) and ultimately debt. Children may experience antisocial behaviour in the temporary unit, have limited space for play or study and rarely have play dates, but often face lengthy journeys or several school transfers.
The lessons I have learnt are too many to list! Networking offers opportunities to learn, advocate and share. Make sure your management and commissioners understand your role and find a way to ensure your client’s voice gets heard.
Queen’s Nurse, Specialist Health Visitor
*All names have been changed.