## Improving Outcomes For Children And Families In The Early Years

A key role for health visiting services Case studies Case studies Case studies Improving outcomes for children and families in the early years

## Contents

| Foreword	                                            | 4             |
|--------------------------------------------|---------------|
| What do health visitors do?                | 5             |
| Why is health visiting important?          | 6             |
| How is the service delivered?              | 8             |
| Local government's new role                | 9             |
| Case studies                               | 10            |
| Universal                                  | 10            |
| Birmingham                                 | 10            |
| West Sussex                                | 11            |
| Leicester City, Leicestershire and Rutland | 12            |
| U                                          | niversal Plus |
| Nottingham City Council                    | 13            |
| Hull City Council                          | 14            |
| Enfield                                    | 15            |
| Universal Partnership Plus                 | 16            |
| Norfolk                                    | 16            |
| Solent                                     | 17            |
| Wolverhampton                              | 18            |
| Community                                  | 19            |
| Walsall                                    | 19            |
| Integration                                | 20            |
| Haringey                                   | 20            |
| Redcar and Cleveland                       | 21            |
| Cheshire East                              | 22            |
| Want to find out more?                     | 23            |

## Foreword

But of course times are tough. Austerity is biting hard and public health funding is being squeezed. Councils have to juggle competing demands and deliver with scarce resources.

Health visitors have a long history. The role dates back to the 1860s - and over the years they've been there for many millions of families, providing valuable support in those early years. That continues today with parents now guaranteed five visits before their child turns three.

1
Make no mistake, though, what happens at the start of life has a major impact on the life chances of children. Health visiting services, working in partnership with other health and community services, can help ensure that start is positive. What could be more important than that?

In 2015 health visiting was brought into the local government fold for the first time since 1974. It gives councils a unique opportunity to build on what has been achieved and help make progress in key areas of public health. Just consider the four domains of the current public health outcomes framework: improving the wider determinants of health, health improvement, health protection and reducing premature mortality. Health visitors can have an impact on all of them through their work in supporting families in the early years, identifying those in need of extra help and ensuring good uptake of immunisations programmes. 

The result of such support cannot be underestimated. It builds resilience, encourages healthy lifestyles and aids social and emotional development. So it has been welcome that we have seen a significant investment in health visiting in the past five years. The numbers were increased and the service has been transformed. But what can councils do to continue and build on this momentum? As with so much of public health, the move into local government offers fresh opportunities. By integrating health visiting with other services, such as children's centres, early help, safeguarding and public health teams, we can provide better support to children and their families.

## What Do Health Visitors Do?

Health visitors are registered nurses or midwives who have completed extra training in specialist community public health nursing. They lead or form part of a wider health visiting team that can also include nursery nurses, health care assistants and other specialist health professionals. They lead and deliver the Department of Health's healthy child programme (HCP) for children aged 0 to five along with other health and social care colleagues, including family nurse partnership teams. The HCP goes on to cover those aged five to 19, but this element involves school nurses rather than health visitors. The HCP is offered to all families and the core elements include health and development reviews, screening, immunisations, social and emotional development, support for parenting and health promotion. The National Institute for Health and Care Excellence describes health visiting as a 
"vital service" which can "build resilience and reduce costs later in life, tackle inequalities and promote healthy lifestyles". It says the service offers a unique opportunity to reach out to families because it is "valued and accepted" as a universal service. The HCP and health visiting became the responsibility of councils in October 2015, completing the transfer of public health functions from the NHS to local government. The vision for health visiting was set out five years ago with the launch of the Health Visitor Implementation Plan in 2011, a joint initiative between the Department of Health, NHS England, Public Health England and Health Education England.

At the heart of the plan was improved access, experience and outcomes for all families. To enable this to happen the government promised to increase the health visiting workforce, to make up for an earlier fall in staff numbers and an increase in the birth rate. Although the target of 4200 extra health visitors was (just) missed, the workforce increased to the point of enabling a 'minimum floor' of one full time health visitor for each 300 children under five years to be employed. 

## Why Is Health Visiting Important? The Six Areas1 Below Have A High Impact On Improving The Health And Wellbeing Outcomes Of Children And Families. Health Visitors Through Their Delivery Of The 0-5 Healthy Child Programme Make A Significant Contribution To Each Of These. Transition To Parenthood And The Early Weeks

•	 Transition to Parenthood and the first 1001 days from Conception to age 2  
is widely recognised as a crucial period in the life course of a developing child.
•	 We know that 80% of brain cell development takes place by age three. •	 There is a significant body of evidence that demonstrates the importance of sensitive 
attuned parenting on the development of the baby's brain and in promoting secure attachment and bonding.

## Health Visitors Are Trained In A Variety Of Parenting Programmes, Targeted And Universal And They Can Signpost To A Wide Range Of Information And Services. Maternal Mental Health

•	 Mental health problems in the perinatal period are very common, affecting up to  
20% of women.
•	 Perinatal mental illnesses cost the NHS and social services around £8.1 billion  
for each annual cohort of births. A significant proportion of this cost relates to adverse impacts on the child.

## Health Visitors Undertake Additional Training And Are Skilled In Assessing Mental Health. Breastfeeding (Initiation And Duration)

•	 Breastfed infants have a reduced risk of respiratory infections, gastroenteritis,  
ear infections, allergic disease and Sudden Infant Death Syndrome. 
•	 Breastfed infants may have better neurological development and be at lower risk  
of tooth decay and cardiovascular disease in later life. 
•	 Breastfeeding can be protective against obesity, particularly in those who are  
genetically predisposed ; breastfeeding for 3 months in the first year of a baby's life reduces the risk of obesity by 7%. 
•	 Women who breastfeed are at lower risk of breast cancer, ovarian cancer and  
hip fractures from reduced bone density.

## Health Visitors Are Able To Provide Practical Help And Advice To Mothers On How To Breastfeed, Help With Managing And Resolving Breastfeeding Problems And Building Community Capacity To Support Breastfeeding By Working With Communities To Establish Peer Support And Programmes. Healthy Weight, Healthy Nutrition (Including Physical Activity)

•	 Children who are overweight are at increased risk of poor health outcomes such as type 2 
diabetes and poor mental health. 
•	 Childhood obesity is a significant health inequality with higher rates amongst children in 
disadvantaged areas and some ethnic groups.

## Health Visitors During Routine Contacts Have The Opportunity To Support Health Promotion And Healthy Lifestyles, Using Evidence - Based Techniques Such As Promotional And Motivational Interviewing. Managing Minor Illnesses And Reducing Hospital Attendance/Admissions

•	 Illness such as gastroenteritis and upper respiratory tract infections, along with injuries 
caused by accidents in the home, are the leading causes of attendances at Accident & Emergency (A&E) and hospitalisation amongst the under 5s.
•	 Unintentional injuries are also a major cause of morbidity and premature mortality for 
children and young people in England. 
•	 Dental extractions are one of the most common reasons for anaesthesia in under 5s and 
tooth decay is now a leading cause of parents seeking medical help and advice.

## Health Visitors Are Able To Provide Help And Support To New Parents On A Range Of Common Minor Childhood Illness Such As Fever, Cough And Colds, Vomiting And Diarrhoea And Also Oral Health. Health, Wellbeing And Development Of The Child Aged 2: Two Year Old Review (Integrated Review) And Support To Be 'Ready For School'

•	 Age 2-2½ is a crucial stage when problems such as speech and language delay, tooth 
decay or behavioural issues become visible and good quality evidence based early intervention improves outcomes.

## Health Visitors Can Intervene To Address Additional Need, Providing Evidence Based Support And Work With Early Years' Providers, School Nurses And Other Community Resources To Support Children To Be Ready For School. How Is The Service Delivered?

•	 Universal (the five key visits) •	 Universal Plus (provide families with access 
to expert advice and support on issues such as postnatal depression, weaning and sleepless children)
As part of the Health Visitor Implementation Plan, a new model of service organisation was developed so the additional staff would be delivering a well-evidenced and improved service. Across the country, the health visiting service has adopted what is known as the 
'4, 5, 6 model'. This encompasses 4 levels of service, 5 mandated elements and 6 high impact areas.

•	 Universal Partnership Plus (support families 
with children with complex needs, such as long-term conditions - both themselves and linking them with local services)
Levels of service:

•	 Community (broad knowledge of local 
resources, including children's centres and self-help groups)

5 
Universal HV reviews* 
4  
Level Health Visiting 
Service model 
•	 Your Community 
•	 Antenatal health 
promoting visits
•	 Universal
•	 New baby review
•	 Universal Plus 
•	 6-8 week assessment 
•	 Universal  
Partnership plus
•	 1 year assessment •	 2 to 2 ½ year review
*
mandated until March 2017
High Impact Areas 
•	 Transition to parenthood and the 
early weeks
•	 Maternal (perinatal) mental health •	 Breastfeeding
•	 Healthy weight •	 Managing minor illnesses & 
reducing accidents 
•	 Health, wellbeing and 
development of child age 2 and support to be 'ready for school'

## Local Government'S New Role

The Institute of Health Visiting (iHV) described the move of health visiting into local government as a "significant landmark", which has the potential to be a "springboard for future development". So what has been happening since responsibility for commissioning the service was transferred from the NHS in October 2015? Some councils have started moving services in-house to help the process of integrating them with existing council services. Others have not taken that step - or not yet anyway - but have still managed to pursue an integration agenda, particularly in terms of delivering the two-year review in more family-friendly settings such as nurseries. There are plenty of other examples of innovation - as the case studies later in this brochure will demonstrate. But there have also been challenges. Concerns have been raised that in some areas health visitor posts are being cut as a consequence of the reductions to local government funding. The cuts to local authority public health budgets make it more important than ever for health visitors and commissioners to work together to monitor and evaluate the impact of the service. Data is collected for key performance indicators, but these mainly focus on the number of core contacts achieved. However, this does not capture the "breadth or depth" of the health visiting service. IHV has produced a toolkit to help commissioners and providers evaluate what is being done, a report on the economic benefits of health visiting and documents about the six high impact areas, published by PHE, include suggested measures of success and outcomes that could be audited.

Top tips: 
•	 give health visiting staff autonomy and 
flexibility - research by King's College London suggests this enables delivery of effective services
•	 whether the service is being brought inhouse or not, explore opportunities for integrated working with other council teams
•	 look at how health visitors can do more to 
promote healthy lifestyles - whether it is physical activity or health eating
•	 invest in specialist health visitor roles as 
they can make a huge difference working with vulnerable groups such as the homeless, refugees and those with mental health problems
•	 consider how digital technologies can 
extend the reach of health visiting
•	 ensure there are clear pathways for health 
visitors to refer children and families into other support services for extra help

## Case Studies Universal

is how difficult it is to get some families to engage. Health visitors have to be quite tenacious - for some you have to try three or four times."

## Birmingham: Improving Uptake Of The Core Service

Birmingham has made great strides in providing a comprehensive universal health visitor service to its local population. Before the national programme was started in 2011, the city's health visitors had to focus largely on providing support to families referred to them by GPs and social care with a limited universal offer. But the national investment allowed it to increase the number of staff working in the service from 135 to 264.

To help, the mandated visits are promoted at the well-baby clinics, which is a dropin service for parents with concerns on everything from sleep problems and nappy rash to speech and language. And last year a communications campaign to promote the service was run in Birmingham and across the Black Country. It involved adverts being placed on Mumsnet and Netmums websites and posters and cards being printed for health visitors to hand out and put on display. GPs and other health and care workers were also engaged with to make sure they were providing consistent messages.

Jane Powell, head of the city's 0 to 5 service, which is run by Birmingham Community Healthcare, says: "Previously we were doing a lot of fire-fighting, but the increase has allowed us to start providing a good universal service with the five mandated visits. That has had a major impact - we're seeing fewer children being placed on care plans because of the early help they get."
It seems to have helped. Latest figures show uptake of the one-year review is over 70 per cent and the two-year check over 60 per cent - up from just over 40 per cent in some teams three years ago. But Birmingham continues to seek to build on what has been achieved. It is currently carrying out a pilot to test the impact of the new ages and stages questionnaire for the two-year check. It involves questions on social and emotional wellbeing. 

However, Ms Powell says it is not just about providing a service - she says you have to work hard to encourage good take-up. You've got to make sure parents know what we do and why it's important. We've thought carefully about the letter inviting them and we try to make sure the same health visitor is used for the first three visits to help build a relationship.

Ms Powell says its introduction is being carefully road-tested to make sure the complexity does not put people off. "One group are sent the questionnaire then seen at home, one carry on with the old questionnaire and a third receive help at a clinic to fill it in. It means we can make sure when we roll it out we are giving parents the best support."
Contact: 
jane.powell@bhamcommunity.nhs.uk
"When the health visitor leaves they explain when the next visit is going to be so the mum is ready and aware. The important thing is taking your time with parents. You can visit a new mum and they can be in tears - you may have to go back the following week. The other issue, which is not always acknowledged, 

## West Sussex: Integrating The Two-Year Review

The good working relationships between the healthy child programme managers and early years commissioners in West Sussex has allowed them to launch a new integrated twoyear review. The review is one of the five mandatory contacts in the HCP and has traditionally been carried out in a children and family centre or health clinic. But the council and health visiting service, provided by Sussex Community NHS Foundation Trust (SCFT), have started changing that in response to national policy change. The reviews are now being done at local nurseries and childcare settings along with the staff and parents. "It is a much friendlier, relaxed and familiar environment," says Julie Warwick, the healthy child programme manager. "That is better for the child and it helps us carry out a much more holistic assessment. Sometimes the child will do things in a nursery setting that they don't do at home. What is more, the early years nursery staff member is familiar with the child and that brings a different perspective and means the parents and two professionals can learn from each other." The concept was first piloted in the summer of 2015 in Crawley, but after being well received the idea has now been rolled out across West Sussex. To help develop integrated working, a series of half-day workshops were run for health visitors, child minders and nursery staff. These enabled different practitioners to network as well as learn about the new initiative. At present, a fifth of two-year-old reviews are carried out in this new way and there are plans in place to incrementally increase the number of integrated two-year reviews, with a specific focus on those who are entitled to free nursery provision at age 2. Feedback from parents has shown that they really appreciate the way the check is done and staff feel the project has been extremely beneficial too.

Allie Wood, one of SCFTs health visitors, says the traditional way of carrying out the reviews only gave a "snapshot" of the child's development. "It was done in a strange environment for the child. I maybe had not met the child before. But the presence of the early years nursery staff has changed all that", she says. "It's nice for the child to see someone he or she recognises and relaxes in front of. That helps with the assessment." She also says by doing it together they can learn from each other and discuss other health promotion aspects, such as immunisations and oral health, which will be important in the future.

Beckie Smith, a senior child care practitioner who has worked with Allie, agrees. "In the past we might have brought up an issue with the parents where other professionals involved may not have been made aware, as information was not always shared." 
Contact: 
julie.warwick2@nhs.net

## Leicester City, Leicestershire And Rutland: Moving Into The Digital Age

a rota basis, which means staff take it in turns to respond to the messages as part of their normal working day. LPT is also looking to set up a dedicated website for parents and carers of children under five. This follows the success of the Health for Kids (www.healthforkids.co.uk) and Health for Teens (www.healthforteens.co.uk) 
websites, which offer age-appropriate advice and information.

health visiting across Leicester, Leicestershire and Rutland is moving into the digital age with a text messaging service for parents and carers. ChatHealth makes it easy for parents to ask health visitors questions about their child's health, wellbeing and development. It builds on a highly successful messaging service developed by Leicestershire Partnership NHS Trust (LPT) to enable teenagers to contact a school nurse for support and advice.

The new 'Health for Under Fives' site will provide information about developmental milestones, advice from health professionals such as dieticians, speech and language therapists and physios. There will also be links to local authority information such as children's centre and library events.

The ChatHealth service was initially launched in 2013 for 11 for 19 year olds locally, and is now being offered by more than 20 other organisations, meaning it is now accessible to an estimated 725,000 young people across the country. The version of the service for parents and carers was launched in October 2016 in six test areas in Leicester City, Leicestershire and Rutland. It is also targeting two specialist services - travelling families and families who are in contact with the early start service.

Design and specification work on the site is well under way and content is being written with a planned launch date of September 2017. Jimmy Endicott, LPT's mobile media development manager, says: "Delivering care through digital platforms is not about replacing face-to-face care, it's about successfully enhancing parental reach, giving choice and encouraging service users to take ownership of their family's health through professional interaction. There are plenty of times when a parent may want to find out more information, but would not consider booking a face-to-face contact. Our digital offer provides an alternative to that."

## Contact: Jimmy.Endicott@Leicspart.Nhs.Uk

LPT is commissioned by Leicester City Council, Leicestershire County Council and Rutland County Council to deliver health visiting and school nursing services. Nicy Turney, LPT's professional health visiting lead, says: "We live in a digital world and know from our service user evaluations that they want to access services in different ways using a range of digital platforms. The professional advice that health visitors will be able to provide through the new digital offer will be evidence based and provided in a way that suits our parents and carers. If a family needs to see a health visitor, they will be signposted to the relevant team." ChatHealth service users receive an immediate, automated response to let them know service provision and emergency contact details if required. They are guaranteed a personal response from a member of the team within 24 hours Monday to Friday 9am from 5pm. The service is run on 

## Nottingham City Council: Encouraging Healthy Eating

With growing concern about child obesity rates, health visitors in Nottingham have been trained to provide healthy eating advice to the parents they work with. This is done through the First Foods Education Programme, which is run in partnership between health visitors and the nutrition team, both of which are commissioned by Nottingham City Council but delivered by community health service provider Nottingham CityCare.

The training gives the health visitors the knowledge and skills to broach the topic of food in all their contacts. They also run groupbased weaning sessions where mothers receive advice about how to prepare food for their babies when they are ready for solids. It comes after it became clear local infants and toddlers were eating high sugar, high salt foods, having low vegetable intakes, relying on too much milk as a toddler and having poor routines. Vicki Watson, the specialist public health dietician involved in developing the First Foods programme, says: "Obesity is obviously a major problem so we wanted to look at helping families develop good habits early on. "Health visitors are in a privileged position. They are invited into people's homes and are really trusted so we have encouraged and helped them to promote healthy eating during their contact with mothers and their babies. They will talk with parents about the sort of food they have in their cupboards and their plans for introducing solid foods, as well as about family eating habits. They have to tailor the messages depending on the people they're dealing with. Some parents don't even know what avocado is or how to prepare broccoli, while others are up to date with all the latest healthy eating advice. Health visitors have to be ready for anything".

During the group sessions mothers get to taste homemade baby food and compare it to manufactured products. There are sometimes practical sessions on how to prepare baby food - emphasising how cheap it can be to produce.

Mothers are also given advice about gagging. "Some are really worried about babies choking so we explain how gagging is a normal reflex and what to do if a baby does choke," says Ms Watson. "We also teach them about responsive feeding - getting them to recognise the signals that babies make. When a baby cries it might be because they are hot or want a cuddle, it is not necessarily a sign of hunger". Parents who have taken part in the sessions are full of praise. Recent feedback has described them as "excellent" and "very informative". Health visitors can also refer families on to other support that is offered in the city, including Eatwell for Life, a cook and eat course designed to increase the consumption of fresh fruit and vegetables and promote healthy cooking skills. Paediatric nurse Alison Barnett, who works as part of the health visiting team, says: "It's really important to offer this advice and support. If we can help mothers adopt healthy eating habits at this age it can make a real difference for the rest of the child's life."

## Contact: Vicki.Watson@Nottinghamcitycare.Nhs.Uk Hull City Council: A Focus On Improving Oral Health

have a toothbrush or share one. Also, with the help of the local dental committee, being able to signpost families to local dentists more accurately has made a huge difference in helping families make that first important appointment".

Whilst children's oral health has improved over the last 20 years nationally, tooth decay continues to be the main oral health problem affecting children in Hull. 

For the first time in Hull, oral health is part of mandatory training requirements for health visitors and the option to complete the new oral health promotion module of the Royal College of Paediatrics and Child Care Healthy Child Programme on Health Education England's e-learning for Healthcare is now available. The training supports the dissemination and implementation of the key evidence based prevention messages to promote children's oral health, provision of key resources and accurate signposting information to local NHS dental services. 

Hull is within the five per cent most deprived local authorities in England. Children living in more deprived areas often experience the biggest burden of poor oral health. Poor oral health can affect children's ability to sleep, eat, speak, play and socialise with other children. As well as causing pain, infections can also interfere with children's nutrition and growth and results in absence from nurseries and schools. For children aged between five and nine years old, the most common reason for hospital admissions is having teeth removed under general anaesthesia.

The inclusion of oral health promotion, including the specific evidence based programmes was a key priority is the recommissioning of 0-19 public health nursing services in Hull in 2015/16. 

Latest oral health data illustrates that nearly 38 per cent of five year old children in Hull experience tooth decay, which is significantly higher than the figures for England and Yorkshire and the Humber. For those children with decay, they will have on average four teeth affected. 

The council also has an Oral Health Advisory Group, where key stakeholders including the council's public health leads, 0-19/health visiting provider leads, NHS England, the Chair of the Local Dental Network, Local Dental Committee and Public Health England continue to ensure an integrated and coordinated approach to help drive oral health improvements locally. 

In 2015, the City's Oral Health Action Plan recognised the importance of health visitors in supporting families ensure that their children's oral health was a priority. Health visitors now distribute dental packs at four and nine months and 2.5 years to all children across the city. In addition, free flow beakers are provided at four months to promote the transition from bottles and prevent prolonged exposure to drinks containing sugar. The packs contain fluoridated toothpaste, a toothbrush and evidence based information for parents/carers to help them look after their child's teeth. 

Tim Fielding, Deputy Director of Public Health at Hull City Council says "We are working hard in the city to make sure that local children have the best start in life. I am delighted that the role of local health visitors in supporting the oral health improvement agenda has been strengthened. Good oral health contributes to school readiness and more of our children will enter school with the right literacy, numeracy and social skills to help them achieve and reach their full potential". Contact: tim.fielding@hull.cc.gov.uk Sally.EapenSimon@phe.gov.uk Carolyn Rabaud, the Senior Operations Manager for Children and Young People at City Healthcare Partnership says "Health visitors now provide the right prevention information consistently and confidently to all parents and carers across the city. The dental packs have been welcomed by families in a city where we know that many children do not 

## Enfield Borough Council: Helping Mums With Mental Health Problems

The early months of motherhood can be very difficult. One in five women suffer some kind of mental health problem during pregnancy or in the first year of their child's life. In recognition of this, Enfield's health visiting service, run by the Barnet, Enfield and Haringey Mental Health Trust, has invested in a specialist health visitor for perinatal mental health. There are two parts to the service. A parttime health visitor works with the Enfield Parent Infant Partnership, which incorporates the local CAHMS service, the London borough's children's service and voluntary sector partners. This provides direct mental health support to mothers. Referrals are made by health visitors, GPs, midwives and children's centres and provides the mother with psychotherapy support or help from the specialist health visitor. Kathy Soderquist, the trust's children's service manager, who oversees the health visiting team, says: "The specialist health visitor works with the named health visitor. The focus is on providing help to the mother in bonding with their baby and helping them to learn how to respond to their baby's cues. "We know the first 1,001 days are critical to the development of the child and so having this extra support can prove invaluable in building the relationship between mother and baby and improving the mother's mental health and the child's future mental health and wellbeing. The level of support varies depending on the mothers circumstances. For some the specialist health visitor may go in each week, while for others it may just be about providing the named health visitor with some help and access to further support if required." The caseload for the specialist health visitor varies, but is typically around the 25 mark. Those who have been helped are full of praise. One mother, Kim (not her real name), believes the support helped her "bond with my baby in a way that I thought I wouldn't". 

Meanwhile, another, Rachel (not her real name), says thanks to the input she became "more confident and less anxious". It was really helpful to have someone to listen and reassure me when I was going through a very difficult time," Rachel adds.

A further element of the work is focussed on training. A second health visitor spends part of their time providing training on mental health issues to the other health visitors as well as key staff, including those working in children's centres. She combines that role with day-to-day health visitor duties. "We wanted to make sure all our staff can pick up on the signs of post-natal depression and mental health problems, know how to help and where to refer too," says Ms Soderquist. "As we employ new health visitors or as new advice is available we can provide training to our team. Mental health problems are so common it is something that everyone needs". 

Contact: 
kathy.soderquist@enfield.nhs.uk stage with the health visitors and any other relevant staff.

## Norfolk: Helping With Child Protection

For the past two years health visitors and social workers in Norfolk have been carrying out joint assessments for children under five deemed in need or at risk of harm. The idea is that by working together they can share the professional analysis and pool understanding of the child and family's situation.

"It gives the health visitor and social worker or early years practitioner a real chance to work together," says Ms Driver. "Before they would be dealing with each other by email and on the phone and then just meet up in cars outside the family's house. This is a much more effective way of carrying out these assessments. They can properly plan who will do the observations, who will ask the questions and so on. That is important - and makes a real difference to the quality of the assessments. They then return to the office and write the report together rather than going back and forth."
The joint assessments are also seen as a way of reducing the "fear factor" of social worker reviews - as the health visitor is often a friendly face - and ensure the assessments are rooted in child development.

The assessments decide whether the child is judged to be "in need" (section 17), "likely to suffer significant harm" (section 47) or if early help is required. Support can then be put in place to help the family, with the health visitor again playing a key role. To help coordinate the work a fortnightly meeting is held between senior members of the relevant teams. 

Carol Manning, Norfolk's head of services and partnerships, says: "Two pairs of eyes are clearly better than one, but what really makes this work is the different skills each brings. It means we have a much fuller picture of the family. The health visitor will know the family, whereas the social workers have the expertise and confidence to judge the risk to the child. They complement each other well. In fact, it has worked so well that early help assessments are now carried out jointly between early years practitioners and health visitors too."
The work is part of a wider programme of integration across Norfolk. Early help hubs have been created in each locality bringing together key partners from health visiting, children's services, police, the voluntary sector and housing to discuss cases. Regular meetings are held to discuss cases and decide what each agency can do to support families.

Contact: 
charlotte.driver1@nhs.net carol.manning@norfolk.gov.uk Charlotte Driver, the HCP lead for the west of the county, agrees. She says by working together they can be "much more effective". In her area the joint working has been taken a step further with health visitors, early years practitioners and social workers working side-by-side on the planning, preparation and writing up of the assessments as well. This has been done through the creation of a hotdesking zone in the health visitors' offices in King's Lynn. When assessments are being prepared the social worker or early help practitioner visits the offices to go through the planning 

## Solent: Working With Children With Disabilities

Southampton City Council and Portsmouth City Council have made supporting families with children with disabilities a priority for health visiting. Across the two cities there are six locality teams with a specialist health visitor for disabilities in place for each. It means if a child is born with disabilities they can be referred to the team early on. Families are provided with all the universal services as well as extra support tailored to their individual needs.

Carol Stevens, the lead for the service, which is run by the Solent NHS Trust, says: "Parents are likely to need more support - whether it is with feeding problems, sleeping problems or just coping with the complexities of the condition. At the start it can be pretty regular contact, perhaps once a month, and then as things settle contact with the family is reduced." As well as providing direct support, the specialist health visitor also helps coordinate input from other agencies, such as CAHMS, physiotherapy and speech and language. "The evidence shows families with children with disabilities are much more likely to experience issues like financial hardship - so it is not just about meeting the needs of the child. There is a lot of different help that can be needed," says Ms Stevens. The contact with the health visitors is for longer than normal too. It can last all the way through to reception year at primary school to help with the settling in period. The service was first launched in Portsmouth seven years ago, before being expanded to Southampton in 2015.

Caseloads vary, although each specialist health visitor can be working with up to 45 families. Only those with the most complex needs, such as severe autism, cerebral palsy and genetic conditions, are referred to the service. Children with less severe disabilities remain under the supervision of the mainstream health visitors, who can ask their specialist colleagues for help and advice if need be. "Families say they find the help invaluable," says Mrs Stevens. "When babies with disabilities are born or an initial diagnosis is made it can be a very difficult time. These health visitors can make a real difference." 
The sentiments are, unsurprisingly, echoed by those parents who have received the support. Pam moved to the area when her son Ryan was two years old. He had been diagnosed with severe developmental delay and hearing loss. "I was relieved when the specialist health visitor contacted me as I didn't know the area or have any family living nearby," she says. "She quickly put me in touch with all the services and followed things up to make sure that we were getting the right support." Pam also received support managing Ryan's behaviour as he was hitting her. The health visitor worked alongside the other professionals involved to improve the behaviour problems and the communication between her and Ryan. "She has always been there to help and give advice. She makes me feel that I am a good mum," Pam adds.

Contact: 
carol.stevens@solent.nhs.uk

## Wolverhampton: Working With The Homeless

When permanent accommodation is arranged Ms Law makes a home visit to assess the environment. "They are often really proud of their new home. They want to show it off, which gives me a chance to have a nosey. I look for those safety risks again and go through them with the mother."
Trudi Law tends to work with mothers intensively over short periods. But the support she provides can help make all the difference as it is provided when they are arguably at their most vulnerable - when they are homeless. Her specialist post - health visitor for the homeless - is one of three funded in the city and provided by the Royal Wolverhampton NHS Trust. The other two focus on teenagers and travellers and asylum seekers. In her role, Ms Law works closely with local refuges, hostels and temporary shelters to ensure pregnant women or those with young children get the support they need straight away.

If risks are identified, Ms Law can arrange a visit from the home safety team, which can fit equipment such as stair gates and bath mats. It is then at this point that she hands over her clients to the mainstream health visitor service. The whole process normally only takes three or four months, although she has found herself working for longer with some families. It means there is a high turnover. During an average month she will get 30 new clients and see 30 move on. "It's really humbling working with these families," says Ms Law. "They are so resilient and so grateful just to have a safe space - it is the sort of things the rest of us take for granted."
Contact: 
trudi.law@nhs.net
"A lot of my clients are extremely fragile," says Ms Law. "They could have been evicted or have fled domestic abuse so they may not be registered with a GP. They have little money and are trying to put their lives back together. In those situations they need support as mothers. At first a lot of it is about fact finding. They normally don't have the parent-held record so we need to go through everything from immunisations to the child's development needs." But the support she provides goes much further than that. She also works closely with other agencies from benefits advice to housing, signposting and coordinating support that is needed. She also focuses heavily on the safety of the child. For most parents when a baby arrives they have spent months planning everything, making their home child-friendly. But the women I care for haven't had that luxury. They maybe living in shared accommodation with communal areas where there are all sorts of risks - older children's toys, cups of tea left unattended, staircases and bunk beds. You have to make sure these things are taken into consideration and the mother is alert to them."

## Community

The walk around the arboretum takes between 45 minutes and one hour, after which the women enjoy lunch in the café. 

## Walsall: Getting Mothers Active And Socialising

A year on, the group continues to flourish. There are now two separate groups - one for new-borns and one for slightly older babies. 

Each week sees at least 10 to 12 women meeting up in each group. The centre has even started to let them use one of the large rooms free-of-charge so the children and mothers can play and socialise.

Physical activity and socialising are known to be two of the best things for the emotional wellbeing of new mothers. The Institute of Health Visiting encourages health visitors to promote both of these through its Ready Steady Mums scheme. The concept is pretty simple. Health visitors work with groups of mothers to help them set up regular weekly meets where they take their babies for a walk in groups. There are about 50 schemes in the country - with the number growing all the time. One of the most successful has been in Walsall.

"It has been wonderful to see how it has grown," says Ms Hollinshead. "The health visitors went to the first meeting just to help the mums settle, but they have taken it on from there. It has become self-sustaining. So now during the First Steps group we tell them all about Ready Steady Mums. We have flyers and posters and it has become a natural thing for the mothers to go on to after First Steps. Socialising and getting some physical activity is so important - that is what we tell them during the groups - so to have a group they can move on to and build on their friendships is great."
Jayne Hollinshead, who worked as part of the health visiting team there until recently, helped local mums to get one up-andrunning at the end of last year. "We really try to support mums in Walsall. We have a local postnatal group called First Steps where we talk to them about all sorts of different things - breastfeeding, preventing accidents and nutrition. And when it came to getting a Ready Steady Mums group going I was fortunate to find two mums who really wanted to do it."
Emily is one of the mothers who has benefited. She says she was so "grateful" to have the support of the Ready Steady Mums group at what was a difficult time. "I made four very valuable friends and we still meet up every week. I struggled with post-natal depression, but the ladies really helped me. It helped me so much."

## Contact: J.Hollinshead@Wlv.Ac.Uk

Between them the mothers and health visitors agreed that the arboretum in the town centre would be an ideal location as it is central to bus routes and has a visitor centre and café with changing facilities. The women agreed to meet up at the same time the First Steps group had been held once the six-week course was finished. 

## Integration

paying a premium to cover that shortfall.  
That has made all the difference."

## Haringey Council: Tackling Recruitment And Retention Problems

Before October 2015 the service had just over 25 full-time equivalent health visitors, but a year later that number had increased to 42. The number of nursery nurses and community nurses also increased from under 10 to nearly 25 during the same period.

The health visiting service in the London borough of Haringey had been struggling to achieve the five mandated visits vision. Due to a shortage of health visitors it had transferred to a targeted offer in 2009 whereby it concentrated on safeguarding and visits immediately post birth.

The increase has also allowed Haringey to revamp its teams moving from four large teams to ten smaller to mirror the council's early help locality teams and children's centre services creating a "virtual team" around the family. It means the two-year reviews can be done in nursery settings where appropriate.

But the move into local government in October 
2015 helped Whittington Health NHS Trust, which delivers the service, turn that around. In April 2016 the one-year and two-year health reviews started being offered and by the autumn the rest of the universal offer followed - a full year before the extended deadline commissioners had given the service.

Investment had also been made in mobile working with health visitors issued with laptops. It all seems to have had an impact. Feedback from parents has been positive, showing they have a good understanding of the HCP offer. Uptake of the new checks has been pleasing too. The one-year and two-year reviews achieved uptake rates of 60 per cent and 50 per cent within the first six months.

Key to the success was the close working relationship with the public health team. A secondment in public health was created for an experienced health visitor to oversee the implementation of the healthy child programme (HCP), while a public health officer was appointed to work with them.

Ms Butler says: "It has been very pleasing. We have come a long way very quickly and look forward to helping make a difference to all families with our new universal offer."
Contact: 
geraldinebutler@nhs.net Geraldine Butler, the health visitor who became the HCP lead, says: "This made a huge difference. It helped us to understand about commissioning and the way local government works, while providing them with a good insight into the problems we are facing. One of the major obstacles to us achieving the five mandated visits was a recruitment and retention problem. That was linked to the fact that we are classed as an outer London borough, but our neighbours are inner London so are funded to pay their health visitors an extra £2,000 a year. That is a lot of money - and meant we were continually losing health visitors to other boroughs. So public health funded us to start 

## Redcar And Cleveland Borough Council: The Benefits Of Moving Health Visiting In-House

The changes in commissioning arrangements were seen by Redcar and Cleveland Borough Council as an opportunity to integrate health visiting with existing early years and children's services. The first step taken by the council was to bring health visiting - as well as school nursing - in-house from the local health trust. This was done first for school nursing in September 2015 and then for health visiting in April 2016 with staff moving across under TUPE. The two services now sit within the people services directorate and are led by the head of service for early help and partnerships. But this is "just the start", according to health visiting and school nursing service manager Susan Walton. "Opportunities have already been identified for the development of integrated pathways with local authority early years colleagues to improve the ways services are provided to children, young people and their families." The health visitor service will continue to be based upon the 4, 5, 6 model and deliver all elements of the healthy child programme. But work has also begun between health visiting and early years to develop an integrated pathway. The vision is that the mandated heath visitor contacts from the healthy child programme will be the universal arm of the pathway and a targeted arm will be developed where both services will work together to ensure that children and families receive the required support in a coordinated way. 

In addition to this, an infant feeding lead post has been created to bring together health visiting and early years services. Prior to this move, an interim specialist infant feeding health visitor worked 15 hours a week. This new role will be full-time and enable the health visiting service to provide training and support to children's centre staff, as well as offer on-going advice and guidance to other colleagues across the council when required. Ms Walton says: "This is a real opportunity for us. The infant feeding lead can deliver training directly to children's centre staff and also work to develop a network of infant feeding key workers within the centres to drive the agenda forward. Staff will be able to access support on a day-to-day basis. The target is that 25 per cent of mothers are still breastfeeding at six to eight weeks. At the moment we are at 24 per cent so we hope this can help us make a difference and get over that mark." Ms Walton says there other plans too, including how they can support GP practices on breastfeeding and working more closely with public health. "There are many different ways we can develop and strengthen joint working now. We were already working closely with colleagues in the local authority, but the transfer has enabled us to take this a step further. That will ultimately benefit the families we are working with."

## Contact: Susan.Walton@Redcar-Cleveland.Gov.Uk Cheshire East Council: Creating A 12-Stop Parent Journey For All

•	 Stop 8 (from 12 months) - play session 
exploring how parents can support and understand their child's language and communication development
•	 Stop 9 (18 to 24 months) - fun and active 
session introducing "five-a-day"
•	 Stop 10 (two years) - integrated review with 
a member of the health visiting team
The five mandated health visitor checks have been incorporated into the wider under fives support to create a 12-stop parent journey in East Cheshire. At each key point along the journey the council provides families with the opportunity to have contact with a relevant key worker - whether it's a health visitor, children's centre worker or member of the early years team. 

•	 Stop 11 (three to four years) - fun and active 
play session with an opportunity to find out about helping the child to play, read and write at home
•	 Stop 12 (before school) - Ready, Steady, 
Play session to support parent and child in getting ready for school.
The aim of the initiative - a partnership between the council's early years, family services and health visiting teams - is to ensure all parents get the best possible support. For those that need it, specialist help in the form of parenting courses and support for breast-feeding and post-natal depression is available. The 12 stops are:

•	 Stop 1 (antenatal) - health visitor visits 
mother at home to talk about their health and their family's health
•	 Stop 2 (antenatal) - session offering advice 
and information on preparing for the arrival of the baby and about the local children's centre
The new approach was rolled out to babies born in April 2016 in three areas with the remaining six localities to follow in February 2017. It has involved 150 frontline staff getting training on the parent pathway and the support they need to offer. And all preschool settings such as nurseries and child minders are being given a linked health visitor to ensure they are part of the 'parent journey'. But apart from the cost of the training and printing of literature which is handed out to parents, the new approach has been entirely funded from existing budgets.

•	 Stop 3 (shortly after birth) - home visit from 
the health visitor to talk about the mother's 
and baby's health and development
•	 Stop 4 (4 to 6 weeks) - home visit from the 
health visitor to support the mother and baby and identify whether other help may be needed
Health visiting and school nursing manager Liz Jones says: "It's really about trying to integrate the way we work. We had been working closely in the past, but this has taken it on to another level. We're sharing records and working side-by-side much more and working in different settings, such as children's centres."

•	 Stop 5 (9 to 16 weeks) - opportunity to meet 
with other parents and babies of a similar age at a children's centre
The new approach will be evaluated as it is rolled out.

Contact: 
carol.sharples@cheshireeast.gov.uk

•	 Stop 6 (4 to 7 months) - session at the local 
children's centre offering advice about making the home safe, communication and language and weaning.
•	 Stop 7 (9 to 12 months) - opportunity to 
discuss the child's health and development with a health visitor.

## Want To Find Out More?

Health visiting programme (NHS England) https://www.england.nhs.uk/ourwork/qualclin-lead/hlth-vistg-prog/
Institute of Health Visiting (2016) Toolkit for measuring outcomes and impact in health visiting practice http://ihv.org.uk/news-and-views/news/newtoolkit-measuring-outcomes-impact-healthvisiting-practice/
NICE briefing on health visiting https://www.nice.org.uk/advice/lgb22/chapter/
What-can-local-authorities-achieve-bycommissioning-high-quality-health-visitingservices Institute of Health Visiting (2016) The economics of health visiting: a universal preventative child and family health promotion programme Department of Health: Commissioning the Healthy Child Programme https://www.gov.uk/government/publications/ transfer-of-0-5-childrens-public-healthcommissioning-to-local-authorities http://ihv.org.uk/news-and-views/news/ economics-health-visiting-universalpreventative-child-family-health-promotionprogramme-report-launched/
Institute of Health Visiting http://ihv.org.uk/
Why health visiting? Examining the potential public health benefits from health visiting practice within a universal service: A narrative review of the literature. International Journal of Nursing Studies 52: 465–480
Royal College of Nursing health visiting pages https://www2.rcn.org.uk/development/ nursing_communities/rcn_forums/children_ and_young_people_field_of_practice/cyp_ healthy/health_visiting Cowley, S., Whittaker K., Malone M., Donetto S., Grigulis A., Maben J. (2014)
The five key visits (NHS England) https://www.england.nhs.uk/ourwork/qualclin-lead/hlth-vistg-prog/5-key-visits/ The high impact areas (Public Health England) https://www.gov.uk/government/publications/ commissioning-of-public-health-services-forchildren Local Government Association Local Government House Smith Square London SW1P 3HZ Telephone 020 7664 3000 Fax 020 7664 3030 Email info@local.gov.uk www.local.gov.uk For a copy in Braille, larger print or audio, please contact us on 020 7664 3000. We consider requests on an individual basis.