Executive summary Health visiting is a statutory, universal service at the core of the Healthy Child Programme. It delivers five mandated health and development reviews for all families with children, alongside non-mandated targeted support when needs are identified. These services are led by Health Visitors (HVs) and delivered by multidisciplinary health visiting teams composed of both HVs and Clinical Skill Mix Staff (CSMS). Since commissioning responsibilities were transferred to Local Authorities in 2015, the service has faced sustained workforce and financial pressures. Drawing on new data collected under the Freedom of Information Act from a large sample of Local Authorities across England, this report documents trends in team composition, caseloads, redeployment during the COVID-19 pandemic, and public spending between 2016 and 2021, and considers their implications for current policy.

The evidence points to a service under sustained strain: most areas have seen substantial reductions in the number of Health Visitors, rising reliance on lower-band staff, and widespread caseloads above recommended levels. Spending on mandated health visiting has fallen by nearly 20% in real terms. Unless workforce rebuilding and sustained investment are prioritised, the ambitions set out in the NHS 10-Year Health Plan and the Department for Education’s new early years strategy will remain structurally constrained. To inform future policy design, we also provide estimates of the staffing increases and associated costs required to restore caseloads to recommended levels under different workforce-mix scenarios.

Key findings

Health Visitors fell by 21% between 2016 and 2021, while Clinical Skill Mix Staff rose by 33%; overall workforce capacity contracted.

Workforce composition shifted across England, with nearly 80% of Local Authorities experiencing a decline in the HV share within their teams.

Caseload pressures were widespread: around 74% of Local Authorities exceed the recommended 250 children per practitioner, with some exceeding 1,000.

During the first wave of COVID-19, 68.7% of Local Authorities redeployed at least one member of their health visiting workforce, often for sustained periods; redeployment was more limited in the second wave.

Spending on mandated services across all Local Authorities in England fell by almost 20% in real terms between 2016-17 and 2024-25.

Spending cuts have been system-wide: while more deprived Local Authorities typically spend more and employ more health visiting staff per child, spending reductions have followed similar trajectories across all deprivation groups, limiting the scope for early-years public health services to address regional inequalities.

Based on 2020 pre-pandemic workforce data scaled to the mid-2024 under-5 population, restoring caseloads to the recommended level of 250 children per practitioner would require hiring around 3,100 staff and an estimated additional £120 million per year in wages.

The authors have declared no competing interest.

Gabriella Conti, Dylan Celestino D’Mello and Yichen Yu gratefully acknowledge support from the European Research Council with the grant agreement 819752 DEVORHBIOSHIP-ERC-2018-COG under the European Unions Horizon 2020 research and innovation program. Gabriella Conti also gratefully acknowledges support from the Leverhulme Trust via the Philip Leverhulme Prize.

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The analyses in this manuscript use a dataset compiled by the authors from Freedom of Information responses provided by Local Authorities and service providers in England, together with publicly available secondary data cited in the manuscript. The compiled FOI-derived analytic dataset is available from the authors upon reasonable request. Publicly available secondary data can be accessed from the original sources referenced in the manuscript.