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LEARNING TO MAKE A DIFFERENCE
STARTING WELL
DEMONSTRATING THAT CHILD HEALTH IN GLASGOW CAN BE IMPROVED BY A PROGRAMME OF ACTIVITIES THAT BOTH SUPPORTS FAMILIES AND PROVIDES THEM WITH ACCESS TO ENHANCED COMMUNITY-BASED RESOURCES. AIMING TO GIVE EVERY CHILD THE BEST POSSIBLE START IN LIFE.
About Starting Well
Led by the Glasgow Healthy City Partnership (with partner organisations representing a range of statutory, voluntary and academic interests), Starting Well combines a programme of intensive home-based support (provided by Health Visitors and Health Support Workers) with a strengthened network of community-based support services for children and their parents. Starting Well is being implemented in two areas of Glasgow (the Gorbals, Govanhill and North Toryglen as well as Greater Easterhouse) which have a total population of around 64,000. The Project will provide intensive support to approximately 1,800 families over a 3-year period.
Key achievements
Intensive home support
Starting Well's first year has seen a period of intense development. Much has already been achieved:
by December 2001, Starting Well's Health Visitors were providing intensive home support to over 600 families - early success stories have been reported
there is a high degree of acceptance in the local community for the project - 98% of eligible families have agreed to take part
innovative operational protocols, including a Family Health Plan and Core Visiting Schedule - have been developed, allowing Health Visitors to work in different ways with families
an innovative partnership management model for the Project's Health Support Worker component has been developed in partnership with One Plus, a voluntary sector organisation, enabling lay Health Support Workers to fulfil a vital role in supporting families: the first lay workers took up post in early 2002
innovative practice guidelines have been developed in partnership with Greater Glasgow Primary Care Trust and the University of Paisley, to inform, guide and improve practice.
INTENSIVE HOME SUPPORT Starting Well's Health Visitors and Health Support Workers are providing intensive home-based support to all families with new babies in the Project's target areas. The focus is on parenting and the provision of practical support. Ideally, contact begins in the ante-natal period. A Family Health Plan is mutually agreed with individual families. Participating families are supported to make better access to local services and agencies. As Alice Mitchell, Health Visitor Co-ordinator in Glasgow's South Side explains, 'Health Visitors naturally have a link into a family with a young child. That link may be reduced as the child matures and the family become more confident and accustomed to living with a new baby. However, in some circumstances there are still parenting issues that the family need support to get through. These could include establishing breastfeeding, helping to get the baby into a sleeping pattern, accessing essential safety equipment as the child begins to crawl and walk, information on what groups are available locally, through to providing specialist health care services if required.' |
MARY AND JIM - A CASE STUDY BY A STARTING WELL HEALTH VISITOR Mary is 21 years old and has four children under the age of 5 years. She had a good relationship with her own parents. While at school, she persistently truanted. Although Mary was considered very intelligent, she did not achieve any academic qualifications. Mary married at 17 years and her two oldest children were born during this relationship (a daughter, now aged 4 years and a son, aged 3 years). As a result of marital problems, Mary separated shortly after the birth of her son and became homeless. She subsequently met a new partner, the father of her second son, now aged 19 months. This partner had a history of drug abuse and crime and was very controlling in his relationship with Mary. The Social Work Department became involved through the Homelessness Team and there were specific concerns regarding child neglect. A Supervision Order was put in place. Mary's relationship with her partner ended and he was imprisoned. Shortly after, Mary entered into a new relationship with Jim, who also has history of drug abuse. (However, he denies any abuse at present.) During the antenatal visit, there was an open discussion with Mary and her partner regarding the Starting Well Project. The Supervision Order was discussed in detail and both parents stated that they would like to have the Order reviewed and removed. Jim was hostile toward the Social Work Department and was abrupt in manner. However, he was willing to accept intensive Health Visitor input. The family was encouraged to register with a GP, the uptake of antenatal care was encouraged and expectations of parental commitment to childcare were discussed. At the same time, I encouraged the parents to discuss both dampness in their home and a broken window with the landlord. The dampness has now been treated. A referral to the local Safety Project was completed. During subsequent home visits, it was observed that there were few toys around and that the parents appeared to be very strict with the children and to have high expectations of their behaviour. I demonstrated positive praise and valuing of children at visits and discussed and praised nice drawings with the children and encouraged Mary to display them. I also discussed the concept of positive parenting and the importance of developing realistic expectations about children's behaviour. Following the visits, Mary's positive approach was becoming evident. Books and drawing materials are now in evidence in the home and the children are now encouraged to sit and draw pictures (which are later displayed on the walls). Mary's fourth baby, a girl, is now 5 months old. This involvement with the Starting Well Project is the longest the family has ever had a Health Visitor. All the children are up to date with Immunisation and Developmental Assessments. Further, they are all registered with a local dentist. Mary states that she would like to attend night school. The family Social Worker has been involved with Mary for many years and has noted marked improvement in home circumstances and parenting. The Supervision Order is being reviewed. |
Enhancing community support
Starting Well is based on the concept of a 'vulnerable community' as opposed to the concept of vulnerable families. Community ownership and support is vital to the Project's eventual success. In tandem with its intensive home-based support programme, Starting Well is enhancing existing networks of community-based support services. These networks are complementing existing services and will maximise the potential skills and energies within the target communities.
Local Implementation Groups have been set up to provide local direction for the Project in each area, along with affiliate schemes to co-ordinate the activities of pre-5 services in each area. Local development funds are enhancing the community-based support available to participating families. Starting Well is being integrated into existing local partnership arrangements and efforts are being made to connect with relevant health and social policy initiatives, such as Sure Start Scotland.
Examples of local activity that Starting Well's Local Implementation Groups are supporting include the Bookstart initiative, extension of existing toy library facilities, local 'drop-in' sessions and community recreation initiatives. As Linda Muirhead, a local parent from the Gorbals, notes, 'In our area, there is little for children to do in the evenings.' Linda is organising Bookstart in the area and the initiative is gaining momentum. 'There is good feedback from parents who may not have realised how important it is to read to young children.'
REHANA and MOHAMMED - A CASE STUDY BY A STARTING WELL HEALTH VISITOR Rehana is a 36-year-old married woman and mother of 3 children: Usman (5 years), Bilal (3 years) and a new baby girl, Faizah (3 months). Both Rehana and her husband, Mohammed, are from Pakistan. Although Rehana speaks little English, she does appear to have good comprehension of the language. The family's previous health visiting experience involved a primary visit to the family home after the birth of the first two children. Continued support was in the form of a 10-15 minute consultation in a busy Clinic environment. The first and second visit to the home proved to be difficult due to the language barrier. Basic information on the baby's feeding and sleep patterns was obtained, though it was impossible to widen the scope of discussion to any other topics involved in health promotion. The Bilingual Worker was introduced to the family on the third visit. Immediately, a vast improvement on the effectiveness of the visit was noted. Not only was it possible to discuss fully all parental concerns of the new baby (skin rashes, feeding problems, Developmental Assessments and future Immunisations), so too was it possible to discuss the well-being of the other siblings. Rehana had major concerns about Bilal's behaviour. Introduction to the Triple P 'tip sheets' was possible, as well as referral to an existing Behaviour Management Group. Rehana also requested an extended nursery placement for Bilal and this was made possible through discussion with Govanhill Action for Parents (GAP). As part of the needs assessment of the family, it was suggested that they be referred to the local Safety Initiative. Within three weeks, the family received a fireguard, a secure lock for their main door, a 'spy' hole for the door and a security gate for the kitchen. Throughout this time, the relationship (through the Bilingual Worker) between the mother and myself grew in trust. Rehana sought advice on parenting on many occasions. She also commented that she enjoyed the regular contact. The Bilingual Worker managed to introduce the idea of community events to Rehana. On the most recent visit, Rehana requested further information on a local Drop-In Centre, and expressed a desire to attend the Toy Library and Patch, a local parenting initiative. |
Challenges faced
Starting Well has made good progress in its first year. However, it has not been an easy road. Early challenges have included:
developing robust partnership working arrangements
recruiting sufficient Health Visitors to deliver the programme
developing a management model for the Health Support Worker component of the Project
managing changes in professional and organisational practice.
Successful resolution of these challenges has depended (and continues to depend) on effective partnership relationships, shared ownership of the Project with key partners and effective communication.
Informing health policy and practice
Fundamentally, Starting Well aims to demonstrate that a programme of intensive home support and enhanced community support can make a real difference to child and family health in vulnerable communities. The Project will offer important lessons regarding:
effective strategies and interventions to improve child and family health (e.g. the effectiveness and acceptability of a programme of intensive home visiting and enhanced community support in a Scottish context)
how to work in partnership with other agencies and disciplines and with local communities to make a real step-change in the health of Scotland's children
organisational development issues (e.g. what is an effective organisational model for intensive support to vulnerable families and how best to deliver this; and the benefits of joint assessment processes)
how to facilitate change (at professional and organisational levels).
A key aspect of Starting Well involves Health Visitors working in a different way with families.
Nursing for Health (Scottish Executive, 2001) set out the future shape of public health nursing practice with families with young children, based upon acting as a resource to the family and targeting efforts to support those with particular needs. Starting Well will help inform the implementation of that vision. Already important learning is emerging regarding:
how the Starting Well model differs from routine health visiting, what training is required to implement the model and how it is best delivered
how to ensure that families are active participants in their own health by increasing families' understanding of their health needs and working in partnership with families to address these
families' support needs (including the specific support needs of ethnic minority families)
how to effectively delegate and make use of others' skills (such as Nursery Nurses) and the value of new roles, such as lay Health Support Workers
the benefits of a Family Health Plan and home visiting guidelines
how to support effective parenting
how to develop and implement evidence-based practice.
Early lessons
Realistic timescales: Starting Well was established within a relatively short period of time. As a result, understandable confusions and unnecessary tensions were created.
Change management: The introduction and integration of a major project among existing Primary Care Services is a complex and difficult task. Even with extensive consultation and communication strategies, the potential for misunderstanding and confusion is significant.
Legal issues: The introduction of lay Health Support Workers to the Project was delayed for a number of reasons, including the decision to place the contract within the voluntary sector and the time needed to develop and agree new legal documents.
Looking to the future
Establishing the Starting Well project over the past year has been a challenging exercise. The Project has overcome a range of strategic and operational hurdles. While meeting each hurdle, Starting Well has also been attempting to provide a quality service to those families that have been recruited. It has been said that what the Project has attempted to do is to build a car and drive it at the same time. With project structures and processes in place and the recent introduction of Health Support Workers to the Project, the car now seems to have been built. Starting Well's continued task is to keep the car moving safely forward. Key milestones in coming months include the launch and implementation of evidence-based practice guidelines. Challenges in Year 2 are to:
address ongoing recruitment difficulties
successfully integrate lay Health Support Workers, Nursery Nurses and other staff into the Primary Care Team
strengthen community links
make effective links with other professionals and voluntary sector organisations
continue efforts to develop more joint approaches to in order to ensure that services are genuinely 'joined up'
strengthen evaluation capacity to ensure that important lessons are captured.
SHONA - A CASE STUDY BY A STARTING WELL HEALTH VISITOR Shona is a mother of three and is in her early twenties. She has a child of 5 years (Findlay), who was born prematurely and who has cerebral palsy. The second child is 4 years old (Catriona) and has some mild developmental delays and behaviour difficulties. Shona has recently had a new baby boy (Callum) who is fit and well. She currently lives alone in a three-bedroom ground floor council flat. There is good support from the extended family that live nearby. Shona likes the area she lives in but the flat is not suited to Findlay's needs. Due to practical problems, Shona finds it difficult to access Clinic services. Through being able to visit frequently at home, I have been able to provide in-depth information to Shona on the normal health and developmental progress of Callum, which is entirely different to her previous experience of health care. Callum was a big baby and Shona felt some pressure to introduce solids at around 10 weeks of age due to his frequent need for formula milk feeds. We discussed the reasons why weaning was recommended at 16 weeks, and Shona was aware of the possible indications that Callum was not ready for solid food. After about a week, Shona informed me that she stopped solid food (as Callum seemed to have stomach upsets which had not previously troubled him) and he continued on milk feeds until 15 weeks. Through the family health assessment process (facilitated by and recorded in the Family Health Plan), Shona expressed a need for a short break with the children, but was anxious about finding a place that would be able to cope with Findlay's particular problems. We were able to link with the resource worker at the local Child Development Centre to find a charity that offered a week break at a centre that regularly catered for children with special needs. We have also begun to use some Triple P resources within the home, specifically the video and workbook, to help Shona address her concerns over how she manages Catriona's behaviour. In recent visits, Shona has begun to discuss her past relationships and the abuse she has suffered. I feel that the development of the level of trust necessary for Shona to be able to discuss these issues has been facilitated through the amount of time we have been able to have together through intensive visiting and in regular telephone discussions. In the future, I will be able to continue to offer her this support. |
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