In response to perinatal and infant mental health challenges, Durham County Council's commissioned health visiting service has significantly advanced its care delivery through a skill mix model and the introduction of specialised roles.
The initiative introduced focuses on early intervention and improving parent-infant relationships, capitalising on a number of evidence-based practices to support family mental health needs.
This case study showcases the service's dedication to community wellbeing and its innovative approach to health visiting in a diverse socioeconomic landscape.
The challenge
The health visiting service in County Durham, amidst ongoing national challenges around staff recruitment and retention, has consistently delivered the national mandated five Healthy Child Programme contacts universally, with an additional 3 locally agreed contacts delivered by enhancing skill mix within current teams and promoting new roles to address relevant, region-specific family needs. They operate across expansive rural and urban communities characterised by varying levels of socioeconomic diversity which present a range of unique challenges.
Central to their mission has been the enhancement of their perinatal mental health support offer. Here, the focus has largely been on offering families targeted early intervention, particularly around parent-infant relationships, ensuring families are connected to specialist services if or when they may be needed.
The team is also deeply engaged in overcoming the challenges associated with promoting breastfeeding and have been working to shift societal attitudes and normalise breastfeeding across the county's varied communities.
The solution
The County Durham health visiting team has been focused on perinatal infant mental health and its outcomes for some time. Its ambitions to build a niche offer for their communities have been reinforced by evidence-based research which shows a lack of formal mental health diagnoses as a leading cause of maternal deaths following discharge (MBRRACE-UK and that specialist health visitors in perinatal and infant mental health significantly impact outcomes (NHS, 2016).
The Parent-Infant Relationships (PAIR) Commissioning Toolkit, published for commissioners in 2023 indicates, approximately, that 30% or 1,350 of infants, babies and children in County Durham have an insecure maternal attachment. More significantly, 15% or 675 children show signs of a disorganised attachment. Continued research around Adverse Childhood Experiences (ACEs) highlights the impact of the parent infant relationship on children’s mental health and behavioural difficulties in the future and the need for earlier, more targeted interventions.
The Family Hub – Start for Life (SFL) programme in County Durham has been the catalyst for a more streamlined, integrated approach to the County’s perinatal mental health offer and allowed the health visiting team to recruit a specialist health visitor for perinatal and infant mental health.
The team has developed clear service pathways and a robust assessment process receiving referrals from the wider system to ensure the right families are targeted and supported.
The perinatal and infant mental health visitor lead and staff nurses within the team handle referrals, triage families and complete assessments to connect them to the right support. Low to moderate mental health needs are supported by the dedicated Perinatal Mental Health team within this service and more complex needs are directed to specialist teams. The newly formed service incorporates:
- Liaison and interlinking with County Durham specialist perinatal services and Talking Therapies, specialised services families are escalated to following triage.
- A Video Interactive Guidance (VIG) offer which is delivered by the new lead, staff nurses and health visitors who have been given full training on its use.
- Health visitors that are trained in delivering the Neonatal Behavioural Observation (NBO) who routinely offer these in new birth visits or at 6-8-week checks. Where Health Visitors feel families need additional support with the parent infant relationship, they refer into the dedicated mailbox, and the specialist perinatal mental health lead will visit the family to do a further assessment using the Neonatal Behaviour Assessment Scale (NBAS).
- Staff nurse visits at the County Durham and Darlington Foundation Trust (CDDFT) Neonatal Unit provide support for families that may suffer low to moderate mental health and difficulties with bonding and attachment while their children are in the unit. Staff nurses link families with health visitors following discharge.
- Emotional wellbeing visits to parents as a series of structured visits to mothers or fathers, depending on who needs the support.
- Family Peer Supporters (FPS) who provide support at home for parents expressing low mood or feelings of isolation and require softer, more personal interventions.
- Triple P for Baby, facilitated by FPS, which is a structured group for both parents offering low level Cognitive behavioural therapy (CBT) to help with unhelpful thoughts.
- Nurturing Little Minds, a more specialised, semi-structured peer support group that offers infant massage, wellbeing walks, crafts or sensory activities children and listening support for mothers.
The impact
The specialist role in perinatal mental health has notably increased the capacity for identifying risk factors for mental health issues early, so relevant support is offered in a timely way.
The VIG has been especially effective in strengthening parent-infant bonds. The tool has played a significant role in showing parents through recorded micro movements that a bond exists and with the additional support of other interventions within the service, mothers are able to begin working actively on the parent-infant relationship.
The collaboration with specialist services and establishment of seamless referral pathways between services has reduced the likelihood of families being discharged without support.
Investing in training and introducing new roles, particularly in delivering emotional wellbeing visits, has equipped staff with the skills to provide targeted support more effectively and address the needs of families experiencing low to moderate mental health issues, a group that may have previously been underserved.
How is the new approach being sustained?
Durham is providing training to its health visiting teams to ensure they have a varied skillset. This includes NBO training; IHV led perinatal & infant mental health training including multi agency training for the family hub workforce; emotional wellbeing visit training; paternal mental health training for dads and carers as well as group and one-to-one supervision sessions led by the specialist health visitor lead.
To measure the outcomes of the support in place, County Durham use established performance measurement tools:
- The Mother Object Relationship Score (MORS) assessment which is carried out before and after any relationship building intervention.
- Goal based outcome assessments carried out by family peer support to understand progress and areas of improvement.
The health visiting team is looking to onboard a clinical child psychologist or psychotherapist to work closely with so the team, including perinatal mental health, can be established as a PAIRS team within County Durham.
Lessons learned
Health visiting teams work closely with families and are well equipped to inform on local priorities and emerging needs. Building interventions with input from the health visiting service helps build offers that are directly aligned to the community. The range of work being led by the IHV has enhanced team understanding of regional and national problems and supported service self-reflection and benchmarking.
Finally, good leadership, a clear vision and trust between decision making and facilitating teams creates a positive working space.
Contact
Susan Duggan
Transformation Manager, 0-25 Family Health Service
Harrogate and District NHS Foundation Trust
Sara Hunter
Perinatal Infant Mental Health Specialist Health Visitor
0-25 Family Health Service
Harrogate and District NHS Foundation Trust