This case study explores the challenges faced, the innovative solutions implemented, the impact of these changes and the lessons learned from this journey.
Derbyshire's health visiting services have undergone a significant transformation, driven by a unique Section 75 agreement and a partnership model between Derbyshire Community Health Services NHS Foundation Trust and Derbyshire County Council.
The challenge
The health visiting service in Derbyshire has faced numerous intricate challenges, primarily driven by financial strains. The increases in pay under the Agenda for Change (AfC) scheme, along with other inflation-related rises, have impacted the ability to continue delivering to the current specification.
A Section 75 Agreement has enabled the commissioner and provider to work in partnership to manage these issues productively and develop short-term strategies to enable the continued delivery of the current service delivery model. Both organisations are committed to working together as part of a transformation project to review the service and develop a longer-term sustainable 0-19 public health nursing model that continues to meet the health needs of Derbyshire families.
The solution
In 2019, just before the COVID-19 pandemic, Derbyshire services entered into a Section 75 agreement, stepping away from its traditional tendered model. Under the new arrangement, the service embraced a more dynamic and collaborative partnership approach with substantially more flexibility. It has been possible to build needs led changes into the service following public consultation, staff feedback and operational insights. Staff are more involved in shaping the service through task and finish groups, contributing ideas directly to options appraisals and with this format there is greater understanding between commissioners and service providers.
In response to challenges posed by COVID-19, Derbyshire secured additional funding to commission research on the pandemic's impact on families. The research showed that universal contacts required more time, particularly due to increased family complexities and needs (e.g. debt, financial or employment concerns). This motivated the service to take on a novel short-term partnership with Citizens Advice to address issues families were dealing with beyond the health visiting team's direct capacity. This created a platform for families needing additional support where they are able to raise a concern with health visitors or a school nurse and be referred to Citizens Advice from within their homes. Citizens Advice aims to answer calls within 3 rings, offering support over the phone or arranging families to visit a local office.
Following an internal audit, partners recognised staff were also hit by the cost-of-living crisis and would benefit from the support available and the Citizens Advice model was extended to staff. Through minimal investment, this approach has helped families clear significant debt and access £1.7m in previously unclaimed benefits. Not only has the joint venture significantly impacted younger populations - who would not traditionally seek support through this route, but the teams involved in setting up this initiative won a Nursing Times Award in 2023.
Despite funding complexities, Derbyshire has found ways to build on its breastfeeding and maternal and infant mental health support offers. There is a dedicated specialist infant feeding team, which despite being small, actively delivers training and provides direct services to mothers with complex feeding issues. Derbyshire’s integrated breastfeeding support service is a peer support service with infant feeding practitioners that deliver support from discharge until day fourteen - to help initiate breastfeeding in the early days until health visitors take over. Derbyshire also contracts out to the Breastfeeding Network who deliver breastfeeding support groups, offer phone support and train volunteers to help increase Derbyshire’s volunteering and overall capacity to support breastfeeding.
There is currently one lead within the maternal and infant mental health service, who following a successful council funded pilot of Video Interactive Guidance (VIG), is also now trained in this area. Positive behavioural outcomes were seen from this pilot and though funding for VIG was discontinued, Derbyshire teams made use of available funds within the framework to provide VIG training to some of their nursing staff to not only complement the variety of mental health and emotional wellbeing training they have, but so that they are ready to use this approach when an opportunity resurfaces.
The service has also set up four week postnatal “My baby and me” groups focused on parental emotional wellbeing (also open to grandparents) and this has been very well received. Various partner organisations have recruited volunteers to work with them on this programme which is now established in various areas. The impact and outcome assessments provide evidence of positive effects on emotional wellbeing and has been followed up with a three- and four-month contact pilot with a weaning element in one of Derbyshire’s most deprived areas. The attendance and engagement have been high and the service is looking to integrate this longer term.
How is the new approach being sustained?
Derbyshire has been proactive and resilient in its approach to serve its community and is sustaining its offers and operations through:
- A partnership approach, capitalising on the effective relationship and transparent communication channels with commissioners that have been nurtured under the Section 75 agreement.
- Engaging staff through task and finish groups, implementing feedback mechanisms to gather frontline insight that can be readily incorporated into service development.
- Conducting options appraisals with commissioners and staff to evaluate potential service changes, ensuring decisions are evidence-based and aligned with capacity and community needs.
- Developing and refining approaches to KPIs and impact assessments. Whilst this is in its early stages, much work is being done to enhance outcome-based metrics.
- Collaborating and maintaining positive relationships with organisations like Citizens Advice and other networks to extend support available to families.
- Employing digital tools like Chat Health for accessible, convenient communication with parents and young people, enhancing service reach.
- Developing dedicated teams and services, such as the specialist infant feeding team and maternal and infant mental health leads, to provide targeted support.
Lessons learned
Amidst competing challenges such as budget constraints, system pressures and non-uniform service operations across regions, it is entirely possible to continue to serve families and their needs through innovation, parallel thinking and resilience.
The shift from a contract-based model to a flexible partnership approach can provide not only space for building solid partnerships, but targeted support for families in need. Working closely and engaging in collaborative decision-making can be substantially more effective enabling both parties to respond to challenges as they arise.
Novel partnerships, such as the one with Citizens Advice, can offer families tailored support for complex social and economic challenges and the adoption of digital tools bridges communication gaps, making health services more accessible and user-friendly. Involving staff in decision-making and problem-solving can lead to more practical and innovative service improvements, highlighting the value of frontline insights.
Contact
Claire Scothern - [email protected]
Claire Scothern, Acting General Manager, Childrens & Continence Services