How are proportionate universalist services affected by resource constraint in practice? Exploring implementation challenges using a synthesis of four health visiting studies in England

BACKGROUND: Proportionate universalism aims to improve overall health while decreasing health inequity across the social spectrum. For health visiting in England, the 'universal' offer is five health reviews for children aged under 5 years, with 'proportionate' support provided through additional health visiting contacts when greater need is identified. METHODS: We synthesised the published findings of four mixed-method studies into variation in health visiting services in England to examine how proportionate universalism works in practice. The studies analysed Community Services Dataset data from 2016-2020 and interviews and observations with parents and professionals (collected 2023-2024). RESULTS: Between 2018 and 2020, up to 98% of infants in 57 areas received their universal contacts, even as services experienced reduced funding and staffing, indicating high reach. However, interview data suggest universal reach was widely achieved by offering a differentiated version of universal contacts based on whether families already have known needs or not. This affects health visiting's ability to identify need across the social spectrum. Similarly, additional contacts were found to be widespread. Health visitors typically reported using these to support families with known complex needs that fell short of thresholds for other services. CONCLUSIONS: In an environment of resource constraint and limited specialist services, a proportionate universalist service will be pushed away from identifying unknown needs and pulled towards supporting the most acute known needs. This may reduce the quality of the universal service, even if reach is maintained. Implications for policymakers and service commissioners are discussed.