Introduction

As with other front-line professionals in health care, health visitors are viewed – and see themselves – as having a seminal role in both the identification of child protection cases and the subsequent management of cases. It is a role which, on a number of criteria, they appear to fulfil satisfactorily (Simpson et al, 1994; Birchall with Hallett, 1995; Lupton et al, 1999b), but which has also been subjected to constraints and tensions. These are derived from the changing political economy of health and primary care and concerns about the future of health visiting. They also reflect debates within the profession about professional–client relationships in the context of a process that has been dominated by judicial considerations and the determination of culpability. Following an account of the performance of health visiting in child protection, this chapter will deliberate the reasons for health visitors’ commitment to child protection matters, whose record contrasts with that of their general practice colleagues. It will identify past and contemporary pressures faced by the profession in maintaining a multifaceted role. In doing so the chapter will explore current debates, which seek to resolve apparently dichotomous demands on the role, and will evaluate the profession's capacity to determine the future direction of the service and the allocation of scarce health visiting resources to child protection work.

An understanding of its history is helpful in contextualising current debates in the profession. Health visiting originated at a time when concerns about urban populations and the spread of disease encouraged the development of a public health movement. By the early 20th century, sanitary reforms had been completed and the state instead began to attend to individual and child health, an approach prompted by the poor physical condition of Boer War recruits. Advice and support for new mothers and the creation of child welfare services became the focus for health visitors’ involvement.