In 2015 we had challenges delivering the 0-5 year Healthy Child Programme; we were unable to deliver the universal antenatal contact and individual appointments for 1 and 2 year health reviews.
Our HV teams comprised a traditional 80 (Health visitor (HV)):20 (skill mix) ratio. We had a high HV vacancy rate and a reliance on agency staff. In partnership with our commissioner and stakeholders we co-designed a new delivery model tailored to local need to ensure that families are seen by the right person with the right skills in accordance with the HCP.
Actions included developing/establishing a:
• Transformation group including commissioners, front line staff and parents
• Bespoke HV capacity model, matching staff knowledge and skills to the mandated contacts and establishing safe staffing levels to deliver the full HCP
• Robust training programme/competency framework validated by Brunel University, overseen by our Professional Development Lead, to ensure safe and effective delivery
• Workforce comprising a unique 60:40 skill mix, increasing numbers of staff nurses to support delivery of the universal new baby review enabling HVs to offer universal antenatal contacts to every expectant woman
The impact has been universal delivery of all 5 mandated contacts and the development of a sustainable workforce model.
Our aspiration was to develop an innovative skill mix model to ensure:
1. Quality of service, through:
- The delivery of the full HCP encompassing the 4-5-6 model of health visiting,
- Early identification of need and improved outcomes for children, meeting all the key performance indicators for both quantity and quality
- Excellent experience for children and families placing them at the centre of delivery
The outcome has been universal delivery of all 5 mandated contacts:
- 90% uptake of antenatal contact
- Client feedback has been very positive
- 95% new baby reviews
- Increased capacity to deliver individual 1 and 2 year reviews increasing from 42% to 66%
2. Improved efficiencies; through workforce development:
- Increasing the number of staff nurses at Band 5 to support delivery of the universal mandated contacts within the HCP, which has enabled us to deliver improved outcomes for both the antenatal and new baby review as highlighted above
- Growing our own health visitors thus reducing our HV vacancy rate and ending our dependency on agency staff
The project allowed us to implement a universal antenatal contact, rather than a targeted contact resulting in early identification of needs within the universal population, and appropriate interventions at an earlier stage.
This means expectant women, mother and children receives five quality mandated contacts, improving longterm outcomes.
The service re-design made efficiencies by releasing health visitor time, enabling health visitors to achieve a 90% uptake of ante-natal contacts, expectant women are offered an early family strengths and needs assessment, support in preparation to become parents, and appropriate packages of care for children/families in need of support. This was achieved despite a 12% reduction in budget.
These outcomes were achieved by:
• A mapping exercise of the remit and roles within the health visiting service
• Developing service policies and guidelines to support induction and training of all staff
• Creating a staff nurse competency framework to build staff nurse skills and knowledge to undertake duties traditionally undertaken by health visitors
• Mentorship and support from the Practice Development Lead
• Recruiting 14 staff nurses to vacant health visitor posts between Sept-2016 and Jan-2017 and subsequently as they have arisen. We have had a high number of applicants and currently have no staff nurse vacancies.
The capacity modelling method used for this re-design has been rolled out across our organisation, ensuring that the right person is in the right role at the right time. The competency framework has also been utilised and adapted within adult nursing teams to support challenges in the district nursing workforce.
When designing the competency and training framework, discussions were held with fellows of the institute of health visiting and two universities took part in a peer-review.
London health visiting communities of practice also peer-reviewed the competency framework and are interested in sharing the innovative model on a wider scale. Our commissioner and clinical service lead have recently shared our experiences with Croydon Community NHS Trust health visiting service and we have also shared the model with Swindon community trust who are both interested in implementing a similar delivery model.
The sustainable workforce model with the expansion of the staff nurse role enabled us to “home-grow” our own qualified health visitors and has reduced our vacancy rate from 21.3% to 7% over the past year.
This has ended our dependency on expensive agency staff (none used since December 2016). We achieve key performance indicators including over 95% of new baby reviews completed within 14 days consistently for the last 18 months.
The new model made efficiencies in the amount of time health visitors could spend face-to-face with families. HRCH service users are receiving face-to-face contacts in the family home for both ante-natal and new baby reviews in comparison to other areas which have moved to a model delivering ante-natal contacts through group sessions or telephone contacts, and new baby reviews may be delayed past 14 days. Client feedback has been very positive.
An audit of the antenatal contacts showed that 100% of clients found the visit helpful, with every visit completed at home. The majority of mothers felt that in comparison to midwives, the health visitors had more time for them to ask questions and felt the health visitors concentrated more on mother’s emotional wellbeing rather than their physical wellbeing.
• We co-designed the new delivery with our commissioner, families, and 0-5 partners (early years services, local safeguarding children board, GPs, social care). Proposed changes and measured outcomes were worked through at commissioner meetings to ensure quality and safety of the changes.
• Our clients and service users were involved in designing the new model through a blue-sky vision event and a survey of their views before the project was undertaken. We monitored client experience using the friends and family test, and a service evaluation completed in 2017.
• Our staff were kept constantly engaged with the project throughout. The health visitors agree that the utilisation of staff nurses to support delivery of the universal ante-natal contact has enabled them to complete more antenatal contacts thus increasing their ability to identify needs during pregnancy. This allows them to offer earlier interventions were necessary, improving outcomes for both parents and children.
• An evaluation workshop was held with the staff nurses to evaluate the effectiveness of project, and what was most challenging. This revealed that they felt they were well supported, they had received high quality training and learning, and they felt prepared for practice and competent care delivery.