Early years high impact area 1: Supporting the transition to parenthood

Question 1

The role of health visitors

Accepted Answer

Health visitors, as public health nurses, use strength-based approaches, building non-dependent relationships to enable efficient and effective working with parents and families to support behaviour change, promote health protection and to keep children safe.

Health visitors also undertake a holistic assessment in partnership with the family, which builds on their strengths as well as identifying any difficulties. It includes the parents’ capacity to meet their infant’s needs, the impact and influence of wider family, community and environmental circumstances.

This period is an important opportunity for health promotion, prevention and early intervention approaches to be delivered. Working with parents and families, health visitors identify the most appropriate level of support and intervention for their individual needs.

Question 2

Healthy Child Programme

Accepted Answer

The Healthy Child Programme offers every family a programme of screening tests, immunisations, developmental reviews, information and guidance to support parenting and healthy choices – all services that children and families need to receive if they are to achieve their optimum health and wellbeing.

The Healthy Child Programme is universal in reach. It sets out a range of public health support in local places to build healthy communities and to reduce inequalities. It also includes a schedule of interventions, which range from services for all through extra help to intensive support.

The Healthy Child Programme is personalised in response. All services and interventions need to be personalised to respond to families’ needs across time. For many families this will be met by the universal offer. More targeted, intensive or specialised support and evidence-based interventions should be provided early to meet ‘predicted, assessed and expressed need’ to improve outcomes.

Question 3

Improving health and wellbeing

Accepted Answer

High Impact Areas support a place-based approach and focus on interventions at the following levels:

individual and family
community
population

The place-based approach offers new opportunities to help meet challenges public health and the health and social care system face. This impacts on the whole community and aims to address issues that exist at the community level, such as poor housing, social isolation, poor or fragmented services, or duplication or gaps in service provision. Health visitors, as leaders in public health and the Healthy Child Programme: Pregnancy and the first 5 years of life, are well placed to support families and communities to engage in this approach. They are essential to the leadership and delivery of integrated services for individuals, communities and population to provide RightCare that maximises place-based systems of care.

Individual and family

Health visitors are valued and accepted by parents, leading to a good uptake of the service. Developing effective relationship with parents should start in the antenatal period, working closely with midwifery services and other partners as needed to provide seamless support and care and a strengths-based approach. Working in partnership with parents and carers to provide individualised care is more likely to promote positive behaviour change and improve health outcomes.

The reliability of needs assessment is also improved through continuity of the health visitor-client relationship. This starts at the universal antenatal review and is revisited at the new birth and the 6 to 8 week reviews. Additional support can also be provided to families identified with additional needs or difficulties in the transition into parenthood.

Health visitors are trained in a variety of universal and targeted interventions which could include parenting programmes and intensive home visiting support. Many of these have good evidence for improving important child and parent outcomes.

Further details about the evidence and implementation requirements of some of these interventions are listed in the Early Intervention Foundation Guidebook. Health visitors can signpost to a wide range of information and improve engagement with other services, such as parenting support, benefits, housing, relationship advice, alongside other resources on health and wellbeing issues including nutrition, perinatal mental health, safer sleep, screening, immunisations and oral health.

The proactive, health-promoting, focus of health visiting means that, particularly in the mid to late phases of pregnancy the service can engage with parents who may not initially have done so. The inter-pregnancy period is another important opportunity to provide continuum of care from one pregnancy to the next, to promote pregnancy planning, fitness for future pregnancies and healthy behaviours in general. This way of working can potentially enhance the uptake and use of services for the future.

The initial antenatal visit at 28 weeks provides a relational basis for assessing mental health for mothers and partners, and supports parents to form an image of their unborn child, laying the ground for parental bonding. Health visitors have in-depth knowledge and advanced skills in assessment, therapeutic communication and care management, which may include:

promoting parental bonding, reflective functioning and parental sensitivity during pregnancy, helping mothers and partners to identify with their baby and bond prenatally
assessing presence of individual risk and resilience factors in families during the perinatal period and using these to determine the level of future health visiting support in line with the safeguarding procedures of their local area
helping parents and carers to manage difficult and challenging issues that are affecting their transition to parenthood, such as parental and infant disability and chronic illness, perinatal depression, toxic stress, previous trauma, family conflict, social isolation and referrals to addiction services
recognising the signs of couple conflict in the parents’ relationship, and discussing relationship issues comfortably and sensitively, offering effective support and referring to specialist services where necessary
supporting parents to understand the health and developmental needs of their children, including the importance of the home learning environment and healthy brain development

Community

Support provided during the antenatal period and early weeks inform the level and type of support needed. This includes identification and response to issues including safeguarding concerns, potential and actual mental health issues, domestic violence and abuse, sexual abuse and substance misuse.

Health visitors can promote information about Healthy Start vouchers to pregnant women, parents and carers of children under 4 years old who may be eligible, and advise on how to use them to increase fruit and vegetables in their family diet, and vitamins for pregnant or breastfeeding women and for children under 4.

Population

Health visitors lead the Healthy Child Programme (0 to 5) and provide leadership at a strategic level to contribute to the development and improvement of policies, pathways and strategies to support delivery of high quality, evidence-based, consistent care for children and families for improving transition to parenthood.

Question 4

Using evidence to support delivery

Accepted Answer

A place-based, or community-centred, approach aims to develop local solutions that draw on all the assets and resources of an area, integrating services and building resilience in communities so that people can take control of their health and wellbeing, and have more influence on the factors that underpin good health and wellbeing.

The All Our Health framework brings together evidence and data that will help to support policy development, evidence based practice and service delivery. This compliments Making Every Contact Count, building on the specialist public health skills of health visitors and the wider health and care professional community.

Most health and care professionals focus on interventions which tend to be delivered on an individual basis, however health visitors and school nurses focus on individuals, families and communities’ approaches. It is critical that all professionals consider the importance of population health as an approach that aims to improve physical and mental health outcomes, promote wellbeing and reduce health inequalities across an entire population.

Social prescribing complements such approaches enabling public health nurses and other health and care professionals to refer people to a range of local, non-clinical services. Health visitors recognise that a child’s health is determined primarily by a range of social, economic and environmental factors which may be affecting the family. Social prescribing seeks to address these needs in a holistic way, allowing individuals to take greater control of their own health.

Question 5

Measures of success or outcome

Accepted Answer

High quality data, analysis tools and resources are available for all public health professionals to identify the health of the local population. This includes child and maternal health profiles and measures of access and service experience, which contributes to decision making process for the commissioning of services and future plans to improve people’s health and reduce inequalities in their area. Health visitors and teams need to demonstrate the impact of improved outcomes. This can be achieved by using local measures.

Access

Measures include:

number of pregnant women who received a first face-to-face antenatal contact with a health visitor
percentage of parents who receive a new birth visit with a health visitor; percentage of children who received a 6 to 8 week review by the time they were 8 weeks as reported through the Community Services Data Set
local measures, such as increased and improved local partnerships, number of referrals, equity audit of access to health visitor mandated contacts and audit of local pathways could be included. These measures would be for local determination

Effective delivery

Measures include:

Measuring impact

Measures include:

uptake of Healthy Start Vouchers: percentage of entitled beneficiaries over eligible beneficiaries
under-18 conceptions: conceptions in women aged under 18 per 1,000 females aged 15 to 17. Quarterly and annual reporting by the Office for National Statistics at local authority level. It is also in the Public Health Outcomes Framework and Early years profiles
proportion of pregnant women who smoke at the time of delivery reported through the Maternity Services Data Set (MSDS) each month. While the MSDS becomes established, smoking status at time of delivery is reported annually in the Public Health Outcomes Framework and Early years profiles based on data collected by NHS Digital
reduced low birth weight of term babies. Collection is through routinely collected birth registration data with annual reporting by Public Health England (PHE) in the Public Health Outcomes Framework and Early years profiles
rate of infant deaths under one year per 1,000 live births. Reporting is via Office for National Statistics, NHS Digital and PHE and in the Public Health Outcomes Framework and Early years profiles
increased breastfeeding rate and lower attrition rate at 6 weeks

User experience

Measures include:

feedback from NHS Friends and Family Test and health visitor service user experience questionnaire on satisfaction with antenatal and new birth review contacts, via local commissioner and provider data

Other measures can be developed locally and could include initiatives within health visitors’ building community capacity role for example developing peer support, engaging fathers, joint developments with parent volunteers and early years services.

Question 6

Connection with other areas

Accepted Answer

The high impact area documents support delivery of the Healthy Child Programme and 0 to 5 agenda, and highlight the link with a number of other interconnecting policy areas such as the maternity transformation programme, childhood obesity, speech, language and communication, immunisations, troubled families, mental health and social mobility action plan. The importance of effective outcomes relies on strong partnership authority including early years services, and voluntary sector services.

Best Start in Life has been identified as a priority as part of PHE’s 5-year strategy which runs from 2020 to 2025. Best start in life is a priority for the government and as such is included in the Prevention Green Paper (Advancing our Health: prevention in the 2020s).

Improving services for children and young people is part of the NHS Long Term Plan. The Child Digital Strategy and Maternity Programme is currently developing and implementing infrastructure to improve access and timeliness of data with the aim to know where every child is and how well they are. This includes the development and implementation of a Digital Parent Child Health Record. This programme supports the ambitions and modernisation of the Healthy Child Programme.

Collaborative working

Approaches to improving outcomes through collaborative working include:

Improvements

improved accessibility for vulnerable groups and reduced non-attendance at appointments
integrated IT systems and information sharing across agencies
systematic collection of user experience to inform action and quality improvement, for example, NHS Friends and Family Test and local service user feedback processes
increased use of prevention and evidence-based interventions and multi-agency programmes to improve parenting, attachment and links to other early years performance indicators
improved partnership working across maternity, specialist perinatal and infant mental health services, school nursing, social care, early years services and education providers
consistent, culturally relevant, accessible information for parents and carers
data on vulnerability factors collected during antenatal visits and new birth visits
identification of risk or resilience factors at individual level using validated screening and assessment tools alongside professional judgement
inclusive care for fathers’ partners and carers

Professional or partnership mobilisation

multi-agency training on infant mental health and best practice approaches to improve attachment and parental attunement
multi-agency training in universal parenting programmes, using principles of positive parenting and focused on how parents and children think, feel and behave
effective delivery of universal, evidence-based prevention and early intervention programmes with personalised support and validated outcome measures
improved understanding of data of local need, evidenced within the Joint Strategic Needs Assessment to inform priority setting by the local Health and Wellbeing Board and its actions via the Joint Health and Wellbeing Strategy
integrated perinatal and infant mental health pathway
identification of skills and competencies to inform integrated working and skill mix
increased integration and working with early years services, specialist perinatal and infant mental health teams and voluntary sector organisations to offer a range of services or activities to promote attuned parenting and positive infant mental health
review provision of local public health services that can support the wider health and wellbeing of families including preconception
upskill other workforces to give public health advice, offer or refer to interventions, for example early years practitioners