The original scope of the project was formulated by the Strategic Network for Child Health and Wellbeing in the East of England and was designed to provide additional support to both providers and commissioners in the delivery of national policy, by:

• Building on and complementing the DH Health Visiting project (Project 4) undertaken in the region to develop a health visiting commissioning specification, develop a toolkit of commissioning specifications that cover the range of services required to deliver an integrated HCP 0-5, both universal and specialist elements:
  • Maternity and midwifery
  • Primary care and General Practice
  • Maternal mental health
  • Children’s centres and early years education
• Providing a methodology to address integrated commissioning that encourages joint working across local government and the NHS to improve child and maternal health outcomes, particularly development at Foundation Stage level.

The Strategic Network for Child Health and Wellbeing in the East of England identified

• Identification of the key commissioning standards and interdependencies for each commissioning organisation identified in the Healthy Child Programme. The standards will be individual specifications based on those already developed in practice including Health Visitor standards developed by Project 4 and other related work streams.
• Identification of a set of measurable outcomes and key performance indicators for commissioners and providers.
• Define the responsibility for monitoring the outcomes for children and young people and how local areas work in partnership to monitor the desired outcomes.
• Production of a model for workforce development across the NHS, local government and third sector to deliver the integrated HCP including a plan of the education and training required to support an integrated workforce.
• Production of an Integrated Commissioning and Delivery toolkit, for the HCP 0 – 5, including the guidance, standards and key performance indicators identified above.

The approach for delivering the project has been based on a clear vision which sought to produce an output that was both inclusive and innovative. Key elements were:

• Ensure we seize the opportunity to facilitate the development, with clinical staff, commissioners, families and other stakeholders, of a product that is based on best practice pathways and can clearly articulate the changes required to ensure the delivery of quality services.
• For the professionals and families to be at the heart of developing objective assessment tools which encapsulate the range of improved outcomes we aim to deliver.
• To ensure that at the same time, all involved in the project understood the importance of, and are able to define within the pathways, all the necessary information required for successful commissioning, service delivery, service management and ultimately quality care.
• To ensure that all stakeholders work on the developments together and are able to develop the depth of understanding of priorities and viewpoints through objective conversations that remove the tensions and change some of the stereotypical behaviours that often prevail.
• To ensure we engage and involve all the necessary skill sets, not just clinicians, throughout all elements of the development – brining to the table their valued thoughts and requirements throughout.

Relationship with Project 4

The brief for the project specifically referenced a need to build on and complement the DH Health Visiting project (Project 4) undertaken in the region.

Project 4 was designed to provide additional support for both providers and commissioners in the delivery of the policy change for the health visiting service following the publication of The Health Visitor Implementation Plan 2011-15 “A Call to Action”.

The key deliverables within project 4 that are relevant to the current project are:

• Develop appropriate Best Practice Pathways
• Identify Key Performance Indicators for Commissioners and providers

Current Project

The overall project was divided into three key phases each with a set of clear deliverables, the phases were:

• Planning & Development Phase
• Intermediate Phase
• Delivery Phase

Planning & Development Phase

The purpose of this phase was to:

• Enable all involved to develop a cohesive understanding of what was required to deliver the overall project objectives.
• Work with the project steering group to co-create the project plan for the delivery phase.

Intermediate Phase

The purpose of this phase was to:

• Develop and ensure the required meeting structure was in place for commencement of delivery phase.
• Ensure all necessary documentation/materials were available to key clinical, commissioning and other stakeholders engaged in the project.

Delivery Phase

The purpose of this phase was to:

• Ensure the effective delivery of the project plan and overall project output requirements.

The project plan consisted of – interrelated components. Figure 1 (below), provides a diagrammatic representation of the interdependencies of these components.

As the diagram illustrates the basis on which the delivery of the integrated commissioning & delivery toolkit is formatted is the Best Practice Pathways. During the pathway development process, in addition to identifying the required clinical interventions, best practice pathway development has also:

• Identified areas of workforce skills and knowledge that are currently perceived as being underdeveloped.
• Informed initial thoughts and key considerations regarding the challenges and opportunities for operational delivery of an integrated HCP 0-5 years.
• Incorporated best practice that promotes the use of outcomes focussed key performance indicators (KPI’s). These have been set alongside a range of provider and commissioner KPI’s to develop a comprehensive suite of KPI’s.

• Identified the key partnership interfaces in the child and families lives which need a systematic and structured approach to ensure continuity of care and service provision.

The formal structure developed to support this project and provide the necessary assurance is identified below (Figure 2).

Project Management

The overall management of the project was provided by a dedicated team of staff from Sustain, each with an identified lead role for the five workstreams. These were:

The Sustain team was supported throughout the project by a dedicated project sponsor, Pamela Agapiou (Director – Universal Service, East Coast Community Healthcare) appointed by the Strategic Network for Child Health & Wellbeing.

The membership of both the steering group and the 5 workstreams was drawn from a range of NHS and local authority providers and commissioners from across the East of England. The full membership of all the groups can be found at appendix 1.

In addition to these groups input was also provided by:

• NHS & LA Commissioning Group
• Eastern Region PIMH Network

Shared Understanding/Definitions

One of the major challenges in developing an integrated approach to commissioning and delivery of the HCP is developing a shared understanding of the statutory duties of the LA in the provision of services to children and families and both the statutory and policy requirements of services provided by the NHS.

Across the range of statutory guidance and policy documentation appropriate to the HCP there are a variety of terms used to describe the level of service provision. In addition, where a common term is used e.g. Universal the definition of the level of service provision varies between documents.

For the purpose of this document we have used the following working definitions:

Universal

The range of services and or interventions that must be delivered/should be available, to children and families within a local area.

Universal Plus

The range of services and or interventions, predominantly by a single profession or service, provided to a targeted group of children and families based on an identified individual need.

Universal Partnership Plus

The range of services and or interventions, by a multi-disciplinary range of professions or services/agencies, provided to a targeted group of children and families based on the identification of more complex individual need.

Transition

A common theme within Serious Case Reviews for children and young people is the communication within and between health and social care teams/systems and across organisational/agency boundaries. Therefore the transition points and communication between services, supported by interagency protocols, are essential to the effective and safe delivery of integrated care.

Both Commissioners and providers within a local health & social care system will need to ensure that appropriate systems and processes exist to ensure effective and safe transition and communication.

Some of the key areas of focus should be:

• Effective notification of pregnancy process between midwifery services, the GP, the Health Visiting services and the relevant local authority services including Children’s centres.
• Ensuring notification is provided to HV services and Children’s centres following the registration of families, who are new to the area, at local GP surgeries.
• Ensuring formal handover of care between midwifery services and HV at the point midwifery services discharge mothers postnatally.
• Ensuring formal handover between HV and school nursing services.
• Development of effective interagency protocols that support effective communication and information sharing particularly relating to safeguarding.

Interdependencies and Seamless Pathways

It is essential that the HCP 0-5 years is not commissioned or provided in isolation of other healthcare services. It is also crucial that operational and strategic relationships with colleagues in local government, such as Children’s centres, are maintained and strengthened. The new commissioning arrangement split responsibility for the commissioning of the children’s pathway between three responsible commissioners. In addition to the HCP 0-5 years, NHS England will commission other important services used by children including primary care services and specialised services. CCG’s will commission Maternity Services, children’s community services and most secondary care services, and local authorities will commission a wide range of services for children. All commissioners share a responsibility for safeguarding.

A range of the interdependencies are represented in Figure 3 below.

To support the effective delivery of the above it would be useful for local systems to develop and agree a formal memorandum of understanding.

Values and Principles

All commissioners and providers need to ensure that the approach taken in both the commissioning and delivery of services supports the national values and principles. In summary this is:

“To ensure that all parents and children have access to the support they need to get off to the best possible start in life, and promote their health and resilience as they grow up. Provide early intervention to ensure additional support for those who need it, including the most vulnerable families.”

HCP Leadership

Whilst all of the professionals delivering services to children and families have a unique and essential role, the HCP specifically identified that the health-visiting workforce was central to its delivery and is defined as:

• leading the delivery of the HCP to a defined population; and
• delivering intensive preventive programmes to the most at-risk families with young children.

Local commissioners through effective workforce planning for the HCP will need to ensure that the health visitor has a lead role in the HCP and has the skills and knowledge needed to lead and deliver the programme.