With more people living in temporary or insecure accommodation than ever before, Madeleine Anderson looks at the role of specialist health visitors providing vital early years advice and support for growing numbers of homeless families across the UK.
For over three decades, Debbie Fawcett has provided care for families living in trading estates, hotels, women’s refuges, traveller sites, and converted office blocks.
During her time as a specialist health visitor for homeless families in London, Ms Fawcett says she has seen rising numbers of families needing care in ‘unusual’ environments, in unsuitable temporary accommodation, or in multipurpose new build sites where many people live in close proximity.
Speaking to Nursing in Practice, she explains that most of the families she visits do not have access to gardens or safe spaces to play, with many homeless families living in single-room accommodation and with limited space.
According to a recent Parliamentary report, one in every 21 children in London is living in temporary accommodation, equivalent to at least one child in every London classroom.
Families who find it difficult to access healthcare
As she cares for families who may be overlooked or find it harder to access or be accessed by mainstream health services – such as asylum seekers or traveller communities – Ms Fawcett does a lot of ‘cold calling’ to identify families who may require support from a health visitor.
‘I don’t feel intimidated by cold calling, it’s the curiosity that comes and leads the way,’ she says.
The families she cares for regularly move around, making it harder for her to provide consistent care and regular check-ups. Given this, she works to ‘make the most’ of each visit, knowing that she may not be able to easily check-in with the family going forward.
‘So, it’s about trying to do as much as you can. And for me, that is a priority,’ Ms Fawcett explains.
Local authorities are not required to differentiate between the age of a child living in temporary accommodation – whether they are a teenager or a baby – which makes it even harder for health visitors to identify families who may need their help.
In 2019, a report by the then Children’s Commissioner for England dismissed much of the temporary accommodation children were being placed in as ‘simply inappropriate’. The report exposed how families were found to be living in single rooms ‘barely bigger than a parking space’ or in shipping containers that were ‘blisteringly hot’ in summer and ‘freezing’ during winter.
Building a bond with homeless families
Given the trauma that the people Ms Fawcett cares for often carry because of their precarious housing or a potentially complicated entry into the UK, she believes building trust is vital to developing a steady relationship with families.
‘You need to smile: it’s one of the simplest things. Say hello, show some warmth and give people a chance to breathe,’ she says.
‘I’m always quite surprised; most people are engaging. It’s incredible how much people are willing to share and open up to their experiences,’ she adds.
Related Article: Health visiting workforce ‘cut beyond the bone in too many areas’
When visiting a building, Ms Fawcett aims to visit all the families in which one family member is pregnant or has a child under five.
She aims to spend a whole day on each site and says that visiting on regular days and for a period of time helps to create a ‘good pattern’ so nearby families know when she will be visiting and can access her services easily.
Beyond doing regular health checks, she also works closely with local charities and schemes to flag services that could benefit homeless families, especially those who are new to the area or have not previously accessed UK health services.
Many of the families that she works with, including asylum seeking families, are registered with a GP but not necessarily with the GP local to them, and ‘lots of people don’t understand what a health visitor is’, adds Ms Fawcett.
The need to build trust
Health visitors who work with homeless families work hard to build the trust and understanding of the people they care for. This is key to reassuring parents and children but also helps to deliver clearer and more practical clinical advice too.
Professor Monica Lakhanpaul, a paediatric consultant and professor of integrated and community child health at University College London, stresses the importance of health visitors being able to build trusting relationships with the families they are caring for.
Beyond building meaningful connections, she adds that the anxiety and stress triggered by a lack of trust can also exacerbate the physical health conditions that families are facing.
‘Families have told us that when they go into temporary accommodation, they already feel disempowered and stigmatised. They already feel like they’ve failed themselves,’ she explained.
She adds: ‘You have to build relationships; you have to build trust, and that takes time.’
Professor Lakhanpaul says local authorities should better support homeless health teams, including specialist health visitors, to best support the vulnerable families in their area.
‘You have to have people sensitive to these families’ needs; you have to have people who are well trained, and you have to have the money that backs that problem,’ she says.
Adapting to unique circumstances
Many of the families that Ms Fawcett works with do not have access to cooking facilities, or appropriate bathroom space for healthy eating or potty training. This means she regularly adapts the advice that is ‘typically’ given to families with babies and young children.
‘It’s about trying to use the healthy child programme as your framework but trying to look at how to respond to a parent in their set of circumstances,’ she says.
She warned that much of the advice she would give to families in a clinic, such as to give a baby pureed fruit and vegetables, is ‘completely useless advice’ for families who have no kitchen facilities and very limited financial resources.
‘It’s about trying to be smart and use what they’ve got,’ she explains.
This may mean advising families on which pre-made food is ultra-processed and best to avoid, and which fruit and vegetables can be easily adapted for babies, such as by mashing up avocado or bananas.
‘Sometimes you can’t do everything you want, but that’s the goal: to do the best you can on each visit,’ she says.
Given the range of challenges facing homeless families, including rising living costs and insecure housing, Ms Fawcett says her specialist role has enabled her to develop ‘basic expertise’ in areas typically outside of health visiting, such as in financial support and housing policy advice, which she uses to reassure parents before moving on to her health tasks.
‘If you’re worrying about where you’re going to live tomorrow, you’re not really going to be thinking so much about your two-year old’s developmental review, because you want to first feel safe and secure,’ she explains.
The problems that homeless families need help with
Jane Williams founded The Magpie Project in 2017, in Newham, east London, to support local mothers with children under five who are living in in temporary and insecure accommodation without access to kitchen facilities.
Ms Williams has a background in the voluntary and charitable sectors and has significant experience supporting vulnerable families locally.
Many of the homeless families she supports are placed in temporary accommodation with just a kettle and no kitchen and so are likely to go without home cooked meals.
Giving advice to families that they cannot implement, including unrealistic cooking or diet tips, risks alienating vulnerable people and causing ‘distress and shame,’ she warns, speaking to Nursing in Practice.
She describes how the group has seen a rise in health conditions caused by insecure and unsanitary accommodation, including scabies in newborn babies, impetigo caused by overcrowded living arrangements, and ringworm.
Until the Covid-19 pandemic, The Magpie Project had a health visitor regularly attending sessions to provide support for families, but this had to stop this due to the growing workload of local health visitors.
They would advise families on where to get everyday health advice, such as from pharmacists and GP practices. She says this was especially critical for the families that the project supports, as many who did not know where to go for advice on minor ailments would attend A&E when looking for advice, especially those living in ‘really extreme and difficult’ situations.
Related Article: Specialist nurse workforce set to ‘half in size’ compared with two decades ago
Since it was founded, the project has also seen a rise in children presenting with intestinal distress, poor nutrition and obesity, especially among those without appropriate kitchen facilities.
The project is currently pushing for increased access to specialist health visitors, because of the need for nuanced advice for vulnerable families.
‘For instance, if you’re giving advice on potty training or sleep, or weaning, a lot of the generic advice that would suit 80% of the population who live in houses with kitchens, and bedrooms and bathrooms, wouldn’t suit our families,’ Ms Williams says.
She gives potty training and co-sleeping as examples of times when health visitors need to be sensitive to the complex housing arrangements that homeless families may be living in.
A lot of the families that the project work with live in places in a poor condition due to the number of other people having to share, and often where the nearest toilet is ‘at least two fire doors away’.
This makes it especially challenging to encourage children’s independence when potty training, meaning the organisation is seeing increasing numbers of children going into nursery, and sometimes even school, without being potty trained.
Co-sleeping is very common for families living in temporary and insecure accommodation, especially if there is not space for a cot or separate beds.
According to a 2022 survey from Shelter, more than a third (35%) of parents receiving support from the charity said their children do not have their own bed.
While acknowledging the need to alert families to the safety risks associated with co-sleeping, especially with young babies, Ms Williams says health visitors must be sensitive to how they relay health advice to families with limited means of adapting how and where they live.
‘If somebody is [living] in a place with literally no floor space for a cot, and the health visitor comes in and says you’re endangering your child by co-sleeping – even if they have no alternative – that could be really distressing and difficult.’
Ms Williams says specialist health visitors for homeless families play a vital role in supporting and reassuring families about common childhood diseases that could cause alarm, such as slapped cheek syndrome and foot and mouth disease.
According to a freedom of information request by Inside Housing, there were 1,684 households with children aged under five living in temporary accommodation in Newham in September 2024.
Ms Williams describes health visitors as a ‘personable entry into health services’, something that is especially critical for families who can be very ‘frightened’ of accessing healthcare support, especially if they have had to pay NHS charges.
‘Health visitors give a really kind and human face to that front line. For us they’re an incredibly important aspect of how our families gain the awareness to be able to navigate health systems, but also to get the support they need around childbirth and early childhood,’ she explains.
Recognising the role of specialist health visitors
Ms Williams says health visitors must be encouraged to have the ‘confidence and agility’ to adapt their messaging and meet the specific needs of the community they are serving.
‘I think that it would be great to move towards a space where health visitors felt like they were able to speak out more about the conditions that they find within people’s homes, and that they had an escalation process around holding housing to account.
‘Wouldn’t it be great if we valorised health visitors and gave them the professional standing that they deserve to be able then to raise these issues with other parts of the system, with local housing departments or with the Home Office,’ she says.
Related Article: Homeless nursing: increased demand, stigma and changing weather
She also works closely with local school nursing and social care teams to signpost them to vulnerable children and parents that Ms Fawcett has identified during her visits.
‘If you’re living in one room, or you don’t know when you’re going to be moved, that has an impact on your mental health, and that’s going to have an impact on your parenting,’ Ms Williams explained.
She cautions that she is not only providing clinical support and advice to families but is also seeking to ‘empower’ families, so they do not become ‘too dependent’ on health visitor’s advice when they are unavailable.
‘You’re trying to make someone feel validated, to feel that bond, and show you’re interested.
‘Sometimes I feel really overwhelmed with it all’, she admits, ‘but in that moment, I am there for them, and that’s the important part; that’s what keeps me going.’
Earlier this year, Nursing in Practice heard how extreme weather patterns were impacting the workload of homeless community nursing teams working with rough sleeping populations.
