Organisation submitting example
Stockport NHS Foundation Trust, in partnership with Pennine Care NHS Foundation Trust
Local authority/local area:
Tameside and Glossop (covers footprint of Tameside Metropolitan Borough Council and part of Derbyshire County Council)
The context and rationale
The idea was to promote sensitive and responsive parenting and infants’ secure early attachment, with families in Tameside and Glossop. In order to achieve this, an Early Attachment Service (EAS) was established in 2006-7. It is based on a unique model that is comprehensive, cost-effective and sustainable. It aims to meet the needs of both those parents who need a high level of professional expertise and skill to help them, as well as those who would benefit from simpler information and support. The service also aims to change the culture amongst practitioners and families in Tameside and Glossop so that the importance of that first relationship, between infant and parent, is understood and valued, and placed at the centre of everyone’s thinking.
Tameside is one of the most deprived local authorities in the UK. There are high levels of mental health problems, and stubbornly high levels of teenage pregnancy, which are associated with poor outcomes for children. The aim of the project was to address these areas. Amongst the 0-19 age group, around 9% are from black and minority ethnic groups and 5.6% are from South Asian backgrounds. Sixty different community languages are spoken in Tameside.
The idea for an Early Attachment Service was based on evidence from scientific studies in the field of attachment. P.O Svanberg’s (2006) research into early attachment relationships in 0-3 year olds was applied to the population size and demographics. His research suggests that around 40% of the families would benefit from some degree of support with parent-infant relationships. In the case of Tameside and Glossop with high levels of deprivation and teenage pregnancy, this percentage could be higher, but at 40% would be well over 4,000 under-3 year olds in Tameside and Glossop at any one time.
• Securely attached 60% (n=6,996)
• Possibly struggling with attachment relationship 20% (n=2,332)
• Struggling with attachment relationship 10% (n=1,166)
• Concerning parent / infant relationship 10% (n=1,166)
Prior to 2006, there was no specific support in early attachment available in Tameside and Glossop. The idea for an EAS came from Tameside and Glossop Child and Adolescent Mental Health Service (CAMHS), and it was supported by the Commissioner for Children and Families, and the Health Visiting and Midwifery Services. Increased parental confidence, an understanding of their relationship with their baby, and improved sensitivity and responsiveness, would empower parents, improve outcomes for children and parents as well as improve use of finite resources. Parents’ concerns about infant sleeping, crying, behaviour and feeding are a considerable demand on services such as Health Visiting, Midwifery and General Practice. Given the numbers of parents who would benefit from early attachment support, a comprehensive prevention and early intervention approach was clearly the only feasible option.
The policy framework at the time, including Every Child Matters, the Child Health Promotion Programme (CHPP) (now the Healthy Child Programme), NICE guidance and the National Service Frameworks for Children, Young People and Maternity Services and Mental Health, all indicated that education of parents about infant mental health was important, and there was much evidence that this should be done antenatally as well as once a baby is born. For mothers, it is estimated that about 15% of women have some symptoms of post-natal depression, and because this often features feelings of alienation from their infant, the CHPP recommended interaction guidance. Fathers’ needs for mental health support are also recognised. Research and policy promoting parent and infant mental health has increased, and attracted greater attention and prominence, since the service was first piloted in 2006.
Since then, the increasing evidence of the consequences and costs to individual families and society of poor attachment, and the importance of early brain development, (e.g Allen and Duncan-Smith, 2009), against a context of reduced public service funding, have meant that it is imperative to develop a service model that is comprehensive, cost effective and sustainable.
The idea for this service model was not based on any other model we were aware of; services that work with families on early attachment are often highly specialised. However, all the individual components of this model are based on published research evidence.
The Tameside and Glossop Early Attachment Service (EAS) aims to:
• Promote the importance of early attachment across Tameside and Glossop.
• Provide a clinical service to improve responsiveness and sensitivity between parents and infants.
• Support and provide intervention to families where there are attachment difficulties.
The service’s client group is parents from conception of their baby to the infant’s third birthday.
In 2005, a successful bid for local Sure Start funding allowed an interested group of two Clinical Psychologists, two Health Visitors and a Midwife to access training in the Brazelton Neonatal Behavioural Assessment Scale (NBAS), the CARE-Index and Solihull Approach. A multi-disciplinary, multi-agency approach was important from the outset. Each professional offered one day a week to a pilot project for one year (2006-2007). This involved training Health Visitors and Midwives in early attachment, offering a small clinical service to two Sure Start areas, and NBAS for babies on the post-natal ward at Tameside General Hospital. During the pilot, parent users of the service and professionals (around 30 of each), were consulted on a future name for the service. There was overwhelming agreement on ‘Early Attachment Service’.
All dimensions of the pilot were evaluated. There had been a big shift in the thinking of Health Visitors and Midwives in how they thought about parent and infant relationship. They, and parents, had become more tuned into the needs of the infant and there were big improvements in parental sensitivity towards their infants.
The key lessons learned were that open communication and frequent reporting to commissioners was important, and that winning the hearts and minds of professionals was essential but not always easy. Working alongside both senior managers and front-line workers in services such as midwifery made a big difference.
Based on the success of the pilot, the EAS was set up in 2007 with a small fixed term investment (1.6 whole time equivalents), to cover the whole of Tameside and Glossop. The Commissioner for Children and Families resourced the service through a combination of reprioritising clinical roles and additional Primary Care Trust funding. The service was provided in partnership between NHS Tameside and Glossop and Pennine Care NHS Foundation Trust. The team members were the two Clinical Psychologists, one of the Health Visitors and the Midwife. Following continued successful evaluations of the service’s work, funding was made permanent and increased slightly. An Early Attachment Specialist Health Visitor for teenage parents has recently been appointed, taking the full staffing complement to 2.83 whole time equivalents. This includes the Clinical Manager who is a Consultant Clinical Psychologist. The Operational Manager is not funded by EAS but is provided from Health Visiting management.
EAS sits within the Tameside and Glossop Integrated Parent Infant Mental Health Care Pathway. This was developed out of the multi-agency Parent Infant Mental Health Strategy. EAS has been closely involved in developing both pieces of work.
EAS has a unique service model, in which the team’s expertise is deployed at different levels, from direct clinical intervention, to consultation, supervision and training of staff from health and partner agencies. In order to achieve maximum reach to parents and service productivity, team members are based in health clinics in localities alongside Health Visiting Teams.
The EAS service model is best represented as a pyramid (see diagram 1 below). Each tier represents a different level of intervention and level of access. The EAS has placed a strong emphasis on promoting understanding of early attachment from the ‘bottom up’, rather than providing a service from the ‘top down’. Culture change can be achieved through communities owning, valuing and sharing an understanding of infant communication, and the importance of that first relationship between infant and parent. This has meant developing resources for parents that are universally available, and organising and facilitating training for practitioners from a wide range of settings. Health Visitors and Midwives take responsibility for the less serious attachment difficulties, and through receiving support from EAS in this work, grow in confidence, knowledge and skill in this vital area. This means that the parents who need the support of more specialist clinical skills the most, are able to access them.
1. ‘Getting it Right from the Start’ DVD and booklet
This is a public health intervention. The EAS developed a booklet with accompanying DVD, on attachment and bonding for new parents. It is a cost effective way of reaching all parents with accessible information. It is sustainable because it requires minimal professional intervention to be effective.
The idea came from consultation with a wide range of local parents who indicated that they wanted information about relating to babies, in an accessible format, which featured parents they could relate to, and included what happens when things go wrong. Local practitioners from a range of services were also consulted: they wanted information that was credible to parents and which would support their work, empowering parents to develop a positive and secure early relationship with their baby.
The development and production of 3-4 years’ supply for parents was funded with £27,500 by the Tameside Children’s Strategic Partnership. Local families and practitioners were filmed in parents’ own homes, Children’s Centres, the Hospital Maternity Unit Delivery Suite and the Neonatal Intensive Care Unit. The parents who agreed to share their experiences and tips in front of the camera represented a range of ages, socio-economic backgrounds, ethnicity and need. Consultation continued over the two year development period. Parents enjoyed participating in the project and were empowered by recognising the skills they had as parents.
The Brazelton Centre UK provided valuable advice on the content, as the Neonatal Behavioural Assessment Scale (NBAS) was a key influence. Local professional media services were commissioned for filming, artwork and design, script writing, editing and voice-over. The Lord Mayor of Tameside composed, and donated, the music.
‘Getting it Right from the Start’ was launched in 2010. A celebration event was held to which the parents and babies involved, professionals and the local press were invited.
The content of the booklet and DVD draw on principles of early attachment, brain research, the NBAS and containment, and is in chapters:
o Attachment and bonding
o Why is it important to develop a good relationship with your baby?
o What can I do to help build this important relationship
o Learning more about your baby
o Soothing a crying baby
o Playing and talking with your baby
o Baby time out signals
o Feeding your baby
o Coping when things are difficult
o Having a sick baby
o Useful contacts and DVD.
Since July 2010, Midwives and Health Visitors have given a copy of the DVD and booklet to every new parent in Tameside and Glossop, either during pregnancy or as soon as possible after birth. It has also been shown on the video loop at the antenatal clinic at the hospital, and at antenatal and post-natal groups. This is a way of ensuring that all parents in Tameside and Glossop have access to information to support the development of healthy parent-infant relationships.
We have tried hard to find the best time to give out the booklet and DVD. It was initially given out at the antenatal ‘booking’ visit at the hospital, typically before 12 weeks’ pregnancy. This was too early but we were constrained by midwives’ time. More recently it has been given to parents either at the 20 week antenatal scan, or later by the Community Midwives and Health Visitors. Depending on which hospital the baby is born at, this can be after the baby is born. In addition Children’s Centres, Children’s Social Care, Connexions, Homestart, Breastfeeding Peer Supporters and the Adult Mental Health team have had a supply. It is used in different groups, for example post-natal depression groups.
2. Brazelton Newborn Behavioural Observation System (NBO)
NBO is a tool that provides an introduction to parents to their newborn’s behaviour, personality and preferences, thereby promoting the development of the parent-infant relationship. It is used with babies from birth to three months old and the process helps build a collaborative relationship between parents and health professionals. All Health Visitors, most Community Midwives as well as some Neonatal Intensive Care Unit and Post Natal ward staff received training in NBO in 2011-12. They are now able to offer it to all parents with newborn babies. NBO activity is recorded on the Health Visitor activity data collection system.
Also offered at this level is the Solihull Approach. This approach to supporting families is based on the principles of containment, reciprocity and behaviour management. Most Health Visitors, some Midwives, Community Nursery Nurses and workers in Early Years, CAMHS and Family Support have received this training, which is facilitated by EAS and Health Visitors.
3. Brazelton Neonatal Behavioural Assessment Scale (NBAS)
NBAS is an in-depth screening tool which assesses infant functioning in autonomic, motor, state and social interactive systems, and identifies infant strengths, personality, and areas that would benefit from support. It is used with babies from birth to eight weeks. Two Health Visitors from each locality are trained and accredited to provide NBAS. Their provision of NBAS and additional knowledge is a valuable resource for the Health Visiting teams in their localities. They also support teams in using NBO and the Solihull Approach. They work closely with the EAS, particularly the EAS team member attached to their locality. NBAS Health Visitors are invited to the fortnightly EAS Clinical Team meetings, to provide support and promote development.
4. EAS Consultation Service, Supervision and Training
EAS provides a structured consultation service for professionals. An EAS team member is attached to each of the five localities, and is based for one day a week alongside the locality Health Visiting team. If a professional is considering referring a family to the service, a formal consultation between the EAS professional and the referrer is conducted, to discuss the best care for the family. The consultation is recorded. Health Visitors and Midwives are encouraged to conduct NBO and Solihull Approach Assessments prior to referral, to inform the discussion and subsequent plan.
Most consultations and referrals come from the Health Visiting, Midwifery and Children’s Social Care, but consultations are also conducted with a range of other services.
Since early attachment training and the EAS were first established, the quality and appropriateness of referrals have increased as practitioners’ knowledge and awareness has grown. The consultation service has become an effective and essential method of ensuring that the limited availability of the EAS team for direct clinical work is used most effectively. There is an EAS Referral Pathway to guide practitioners.
The EAS team provides clinical supervision for professionals through the locality structure, and has close links with the NBAS Health Visitors. For example, after consultation it may be agreed that the Health Visitor is best placed to support the family with attachment issues, and the EAS professional will provide specialist supervision while this work is taking place.
EAS also provides a range of multi-agency training in early attachment for practitioners at different levels. Attendees have included workers from Early Years and Children’s Centres, Mental Health, Children’s Social Care, Maternity, Health Visiting Teams, Speech and Language Therapy, Infant feeding, and the voluntary sector (Barnardo’s and Homestart). EAS currently leads on provision of training in the multi-agency Parent-Infant Mental Health Care Pathways. EAS also provides training at the local university for student Health Visitors.
The EAS team also has a role in influencing broader service development. For example, a Parent-Infant Mental Health Strategy, and associated Ante-Natal and Post-Natal Care Pathways have been developed, and EAS made a major contribution to this.
5. Direct Specialised Clinical Intervention
EAS offers a direct clinical service for one day a week to each of the five localities in Tameside and Glossop. The team also works closely with the Post-Natal Ward and Neonatal Intensive Care Unit at the local hospital, attends the Ante-Natal Clinic as needed, has provided and influenced change in Ante-Natal classes, works with Specialist Midwives for Mental Health, Safeguarding and Teenagers, offers half a day a week to the Fostering and Adoption team, and runs a group with the Clinical Psychologist for the Integrated Service for Children with Additional Needs, based on ‘Watch, Wait and Wonder’ principles. Other key relationships are with Community Mental Health (Adult), Primary Care Mental Health, Young People’s Mental Health, General Practice and Children’s Social Care and multi-agency Early Intervention teams.
Any practitioner can refer to EAS service, but referrals are managed through the consultation service (see above). There is a referral form to complete and a leaflet explaining the parameters of the service to help services refer appropriately. The EAS referral pathway, informed by the recommendations of a Serious Case Review, aims to ensure appropriate and timely referrals to the service. The following criteria are emphasised:
• Family are willing to engage and work voluntarily with EAS;
• Safeguarding issues have been stabilized; and
• EAS deems there are some positive signs indicating the possibility for productive working with EAS.
The team engage with common assessment processes. The General Practitioner and referrer are updated with regular progress reports from the EAS professional.
A range of interventions is offered to parents, including video feedback, interaction guidance, parent-infant psychotherapy, psychotherapy, supportive counselling, NBAS, and the parent-child game.
Many families seen by EAS are overburdened with risk and there is a prevalence of neglect and abuse in infants. Currently a risk assessment for this age group is not available. EAS is in the process of devising one for the service that will be used at all consultations and with all families seen by the service.
The EAS team meets fortnightly to discuss clinical issues and developments. They each receive weekly clinical supervision, and monthly Safeguarding supervision is given to the team by the Named Nurse for Children’s Safeguarding. A management / business meeting is held once every six weeks.
Evidence and evaluation - making a difference to children, young people and families
EAS has a wide range of data, evaluations, feedback and performance measures to demonstrate the impact of its work on children and families.
Service Key Performance Indicators
The service has two Key Performance Indicators (KPI) per year that are reported to commissioners, as well as patient activity targets. One KPI focuses on the difference made to families as a result of clinical intervention. The Parent-Infant Relationship Global Assessment Scale (PIR-GAS) is used, and an improvement in the parent infant relationship of one or more levels is measured. In 2011-12, 79.8% of parents receiving treatment (n= 71 out of 89 parents) achieved this improvement. The increasing depth and complexity of problems experienced by families who are referred to the service, makes this a challenging but important measurement.
The second KPI focuses on the training, consultation and supervision responsibilities of EAS. In 2011-12, the percentage of professionals reporting that their consultation with the EAS has had a positive impact on families was measured, and this was 100% (n= 170).
Other data, evaluations, feedback and performance measures is listed below in relation to the different levels of the service:
1. Universal distribution of ‘Getting it Right from the Start’ DVD and booklet
a. Positive practitioner and parent comments and feedback from project planning consultations and launch.
b. A recent formal evaluation study, in which the knowledge and confidence of parents who had received the booklet and DVD in Tameside and Glossop was compared with that of parents in a statistical neighbour site who had not received it, has demonstrated statistically significant benefits.
c. ‘Getting it Right from the Start’ has been a useful resource for practitioners from statutory and voluntary organisations in developing their own knowledge and confidence in this area. As a common resource, it has become part of a ‘shared language’ between professionals, agencies and parents.
d. There has been a great deal of interest from across the country, and we have made a number of sales to other organisations. The DVD is currently being translated into Sylheti, a Bengali dialect and our most common community language.
e. ‘Getting it Right from the Start’ was featured in NHS North West’s ‘Improving Outcomes and Ensuring Quality: a guide for commissioners and providers of perinatal and infant mental health services.
f. ‘Getting it Right from the Start’ is featured in an on-line resource for professionals: ‘Preparation for Birth and Beyond’(Department of Health).
a. Evaluation of Practitioners’ knowledge and attitudes pre and post NBO training, shows statistically significant improvements.
a. A recent case study from EAS Team member of recent NBAS shows the positive outcome for a NBAS.
b. Four health visitors successfully achieved NBAS certification in 2009 and are now able to offer NBAS services to their specific locality. In 2009-2010, the health visitors completed 78 NBAS assessments.
4. Training, Consultation Service and Supervision
A 2007 Pilot Report and Annual Reports from 2009-10 and 2010-11, and information from the draft 2011-12 Annual Report, contain evidence and evaluation of the following areas:
a. Parentcraft classes (Antenatal classes)
b. EAS Attachment Awareness Training
c. Professional Consultation Service
d. Parent Infant Mental Health Pathway Training
e. There is considerable anecdotal evidence that practitioners use their early attachment training in their day-to-day work with a positive effect on outcomes for families. For example, the Infant Feeding Co-ordinator uses ‘Getting it Right from the Start’ and her NBO training in supporting mothers who are experiencing breastfeeding difficulties, and believes that the resources and discussion around infant communication and sleeping / feeding cues help mothers to continue to breastfeed. Health Visitors and Midwives score highly in these knowledge areas in UNICEF ‘Baby Friendly’ assessments.
5. Direct Clinical Intervention
A number of specific measures are used to monitor the effectiveness of EAS’s work with families. PIR-GAS, the Maternal Object Relations Scale, the Ages and Stages Questionnaire and General Health Questionnaire are used with every family the service works with directly. NBAS and the CARE-Index are also used with some families. Information about the outcomes from these measurement tools is available on request.
The 2007 Pilot Report and Annual Reports from 2009-10 and 2010-11, and information from the draft 2011-12 Annual Report contain evidence and evaluation of the following areas:
a. Numbers of families receiving a service
b. Ethnicity of parents
c. Teenage parents
d. Age of infants
e. Children’s social care / Safeguarding involvement
f. Presenting problems for infant and parent
g. Seriousness of problems
h. Treatments provided
i. Clinician rating of change using PIR-GAS, (pre and post intervention)
j. Parent feedback
i. ‘Experience of Service’ Questionnaire
ii. Qualitative feedback.
Sustaining and replicating your practice
The EAS model delivers a comprehensive, cost effective and sustainable service, and for this reason has achieved permanent funding. Services have to be responsive to changing priorities in the population and the constantly changing political and economic climate. A small service such as EAS risks being a victim of its own success; for example being overwhelmed with referrals for Children’s Social Care and requests for assessments for court proceedings. This model allows the service to flex and respond to changing demands, within a framework of both targeted and universal service provision. It allows recognition for the importance of broad workforce and service development and collaborative approaches in sustainability, rather than investing only in a high degree of specialism. It is important to communicate this with partner agencies, and to this end have developed a Practitioner Referral leaflet. The clinical work of EAS has to be of a high standard, as the team are working with complex families and also need to be credible in the support they provide to other practitioners. Therefore ongoing training and development is also important.
Initiatives such as EAS, ‘big picture thinking’ from the outset is essential, however humble the beginnings. This means having a vision of what a service’s potential is, and thinking widely and imaginatively. EAS is still a relatively small service and is only funded for the posts described. Training and developments such as NBO and ‘Getting it Right from the Start’ have been funded by occasional slippages and grants. Having a vision has meant that we have been ready to take advantage of these opportunities, which have often been unexpected and had short turn-around times. It is a case of being patient, but ready to embrace any opportunity, big or small. An example of this is that once trained, it has taken time for Health Visitors to find time to embed NBO into their practice, but the arrival of the Health Visitor Implementation Plan, requiring increased input to new and expectant parents, has now provided the perfect opportunity to take this forward.
‘Getting it Right from the Start’ was another example of this. EAS wanted to provide a resource for local parents, because there was nothing else suitable found and similar resources that had been produced elsewhere were no longer available once their particular projects finished. This frustrating experience meant that it was decided to produce the resource in a more sustainable way, so that it could be used by other organisations. As a result, many parents outside our local area have benefited from the investment, and its popularity with outside organisations has meant that the supply to local parents, and further development, has become self-funding. The contribution that evidence of effectiveness makes to sustaining this initiative both locally and further afield was appreciated, so this has been an added benefit of the ‘Getting it Right from the Start’ evaluation study.
Tenacity has been important in establishing EAS in the hearts and minds of practitioners, and developing their practice. Some teams have been easier to engage than others. It has been important to base EAS team members alongside other community teams (Health Visitor teams) and have regular and consistent arrangements elsewhere, for example the Maternity and Neonatal Intensive Care Units. For some challenges we have had to think creatively, for example we know not all parents are receiving ‘Getting it Right from the Start’ early enough, and some may lose it. Posters and flyers have been developed to put in GP surgeries, community and hospital clinics and Children’s Centres to remind parents and practitioners. The Health Visitor Implementation Plan means that Health Visitors are aiming to deliver universal antenatal visits, and in Tameside and Glossop, orientation to ‘Getting it Right from the Start’ will be a key part of this contact. It was hoped this would make distribution more reliable and consistent.
It has been extremely important, as an innovative and small (therefore potentially vulnerable) service, to have robust measurements of activity and outcomes. This is a culture that was established from the outset, and has been key in building a strong relationship with the Commissioner for Children and Families. The Commissioner has been the service’s strongest advocate, sharing the vision for the EAS, meaning that it has been embedded strategically as well as in a practical sense.
Consultation, feedback and evaluation are essential but are difficult and time consuming to fit in. For this reason, there are still many areas of activity and outcomes that could be measured and collated but are not. Just sending questionnaires out always gets a disappointing response; someone needs to get out to parents, teams and clinics to do it. It is most effective when it is someone’s whole job, so we gave a voluntary research assistant placement to a university psychology student during the summer holidays. She was the key to getting such good numbers in the ‘Getting it Right from the Start’ evaluation, and helped finish some other work. EAS benefited, and the work experience was valuable in helping her gain a prestigious post-graduation research post. A small amount of slippage allowed us to pay a member of staff for some extra hours to complete the ‘Getting it Right from the Start’ evaluation.
Parents were regularly consulted and involved parents in service design and developments, as well as collecting feedback routinely from every parent who receives a direct service from EAS. The time invested has always been worthwhile. The involvement of parents in the creation of ‘Getting it Right from the Start’ demonstrates real community involvement, and parents were very happy to share their knowledge and experiences to help other parents. Parents guided us in developing and producing the resource locally, so that they could relate to the messages being given.
The EAS could easily be replicated in other areas for a relatively low cost, given the reach it can achieve. The service model has already been shared with interested parties, and a number of presentations have been given. ‘Getting it Right from the Start’ has been ordered by services and individual practitioners from all over the country. It works well with the model used but practitioners have also found it helpful in many other settings. For Health Visitors developing their service in response to the ‘Health Visiting Implementation Plan’, it is a very useful tool.
• Unite to succeed – the right support at the right time
• Culture not Structure – learning together
• Shape Up and Keep Fit – learning together
• From Good to Great – leadership, vision and embedding is key
Prove It – making change happen
• Know your Communities,
• It Takes a Community to Raise a Child – see the bigger picture
• Together with Children, Parents and Families – involve service users.
The following additional documents are available from the C4EO team at the NFER .
• Annual report 2009-2010
• Annual report 2010-2011
• Tameside and Glossop Early Attachment Pilot Project
• Parent and practitioner comments
• Referral pathway
• Pre-Training Questionnaire Results
• Additional outcome information.
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