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From the ground up: the development and implementation to date of a local Healthy Child programme and integrated pathway for maternal and child health.

The Healthy Child programme (HCP) (1) and Child Health Strategy (2) highlight the need for multi-agency universal services and seamless integrated working. Along with local recognition of the need to embed integration and joint working as best practice, these key documents prompted a review of multi-agency universal services in Bassetlaw Primary Care Trust (PCT), which became NHS Bassetlaw in 2010.


A locally-developed draft HCP was drawn up and taken to a large key stakeholder consultation exercise to gather gaps and needs in service. The complete local HCP is due to be launched this year. (3)


Maternity matters (4) called for reform to deliver high quality, safe and accessible maternity services through the introduction of a new national choice guarantee for women. The HCP (1) built on the National Service Framework for children, young people and maternity services,5 to provide preventative services tailored to children's and families individual needs. It aims to:

* Emphasise the promotion of child health and wellbeing in pregnancy and the first five years of life

* Support progressive universalism--a core programme for all children, with additional services for children and families with particular needs and risks

* Encourage inter-agency partnership working on local service development

* Focus services on changing public health priorities--obesity, breastfeeding, and social and emotional development.

Through the work of the trust's maternity action and child health promotion groups, a need was highlighted to clarify a core service for maternity and child health. As a result, an integrated maternity and child health pathway was created. The pathway is intended to define the core universal service that should be delivered to all women, their partners and babies within the locality. It uses national clinical guidance, reform agendas and recommendations to furnish the PCT and local providers with a specification for service delivery. The pathway's implementation will ensure consistent clinical practice and enhanced partnership working with all key stakeholders involved in the delivery of maternity and child health services, fulfilling NHS Bassetlaw's obligation to deliver both Maternity matters and the HCP.

Developing the pathway

Bassetlaw PCT established a multi-agency child health promotion group that has been running for a five years (now a child health strategy group). This is led and chaired by the PCT and focuses on developing the provision of the HCP through an integrated children's service approach. A key workstream was to develop a path that would link the outcomes of Maternity matters, the HCP and children's centres.

The child health manager, service development manager and a children's centre coordinator led and developed the pathway for maternal and infant health jointly.

Consultation with stakeholders

The pathway was developed through the work of the trust's child health promotion group and Maternity matters steering and action group, which are well attended by a cross-section of multi-agency professionals. Throughout its development, the PCT has worked in partnership and continually consulted a range of stakeholders, including GPs, obstetricians, midwives, health visitors, head teachers, school nurses, children's centre staff (co-ordinators and support workers), professionals who work with vulnerable groups, the voluntary sector and service users. A stakeholder event in June 2008 provided an opportunity for over 80 delegates to contribute to the development of the pathway. Further consultation took place with GPs, practice nurses and the PCT practice-based commissioning forum.

Validation of key contacts

The pathway clarifies key universal contacts in line with relevant national and local guidance. (1,4,6-16)

Each recommended contact has been further validated and agreed through working in partnership with the key stakeholders involved in the pathway's delivery.

Links to local strategy and targets

The development of an integrated approach to maternity and child health services is set out as a key milestone within the PCT's five-year strategic plan. (17)

The provision of effective conception and antenatal and postnatal care lays a foundation to support the prevention of low birthweights, childhood obesity and childhood diseases, with a reduction in avoidable injuries and smoking during pregnancy. Improved outcomes that are hoped to be associated with the pathway's implementation include:

* Healthy pregnancies

* Uptake of screening and immunisations

* Reduction in maternal obesity

* Reduction in childhood obesity

* Smoking cessation in pregnancy

* Improved preconception health

* Healthy Start

* Breastfeeding initiation and continuity.

The delivery of the pathway is also linked to a number of local operational plan vital signs, targets and performance metrics to:

* Increase the number of women booking with a maternity professional by 12 weeks

* Increase uptake of public health screening reports

* Reduce childhood obesity

* Reduce smoking at delivery

* Increase breastfeeding initiation, linking with childhood obesity

* Increase breastfeeding continuation at six to eight weeks, also linking with childhood obesity.

Each of these are linked to deliverables set out in the PCT's five-year strategic plan. (17)

Delivering the pathway

The pathway sets out core contacts that should be made available to all women, their babies and families. Providers of each service should provide this core level of care for all women.

The PCT has committed significant financial investment to Doncaster and Bassetlaw Hospitals (DBH) NHS Foundation Trust to support the recruitment of a number of midwives and members of the midwifery team. This increase to staff levels has resulted in early implementation of the Maternity matters reform agenda. The hospital's head of midwifery has confirmed that there is adequate midwifery capacity in place to provide the care set out within the integrated pathway. To ensure that improvements and changes to local services are sustained, a dedicated maternity specification has been developed for inclusion in the DBH contract, underpinned by key performance indicators and a maternity minimum dataset. The purpose of this specification is to set out standards for the service provider, ensure that the provider's responsibilities are clear, raise awareness of the scope of services, require the provider co-operates and collaborates with others to provide the service. In addition, a section within the quality schedule of the DBH contract sets out a range of clinical quality performance indicators that are specific to the provision of maternity services.

The health visiting service is experiencing a reduction in capacity due to staff vacancies, which is both a local and national issue. In line with the on-going proposed health visiting redesign that was influenced by and in response to Facing the future, (18) a proposed provision of service is in development to ensure adequate provision of staff with appropriate skill sets and competencies that will support delivery of each of the elements of the pathway. The intention is to move forward with this imminently in order to ensure as little disruption to the quality of service delivery as possible.

Leverage to influence service provision

Reference to the pathway was also set out within the 'Schedule 14: Documents relied upon' section of the PCT's provider arm contract as a temporary measure prior to completion of the service specifications.

The service specifications for the local provider arm contract have now been agreed and reflect the integrated pathway, providing the commissioning function with leverage to performance manage provider arm services.

Next steps

Alongside ensuring the pathway's implementation and sustainability, continued work is required across children's services in:

* Working with fathers

* Establishing lead roles for named health visitors with children's centres

* Re-establishing a lead role for named health visitors with general practices

* Sharing the pathway

* Integrated children's workforce training and development opportunities

* Integrated approach to parent education

* Using 'lean thinking' where appropriate

* Pathway audit, evaluation and update

* Developing the pathway to encompass conception to 19 years.


(1) Department of Health. Healthy Child programme: pregnancy and the first five years of life. London: Department of Health, 2009.

(2) Department of Health. Healthy lives, brighter futures: the strategy for children and young people's health. London: Department of Health, 2009.

(3) Waring V, Hunt J, Cook F. Bassetlaw integrated Healthy Child programme. Retford: NHS Bassetlaw, 2010.

(4) Department of Health. Maternity matters: choice, access and continuity of care in a safe service. London: Department of Health, 2007.

(5) Department of Health, Department for Education and Skills. National Service Framework for children, young people and maternity services. London: Department of Health, 2004.

(6) National Institute for Health and Clinical Excellence. Antenatal care: routine care for the healthy pregnant woman. London: National Institute for Health and Clinical Excellence, 2008.

(7) National Institute for Health and Clinical Excellence. Antenatal and postnatal mental health: clinical management and service guidance. London: National Institute for Health and Clinical Excellence, 2007.

(8) Burke C, Waring V. Practice guidance: maternal mental health. Retford: Bassetlaw Primary Care Trust, 2008.

(9) National Institute for Health and Clinical Excellence. Induction of labour. London: National Institute for Health and Clinical Excellence, 2008.

(10) National Institute for Health and Clinical Excellence. Intrapartum care: management and delivery of care to women in labour. London: National Institute for Health and Clinical Excellence, 2007.

(11) National Institute for Health and Clinical Excellence. Caesarean section. London: National Institute for Health and Clinical Excellence, 2004.

(12) National Institute for Health and Clinical Excellence. Postnatal care: routine postnatal care of women and their babies. London: National Institute for Health and Clinical Excellence, 2006.

(13) NHS Immunisation InformationJmmunisation schedule. See: (accessed 8 April 2010).

(14) Bookstart. Bookstart: professionals. Available at: (accessed 24 March 2010).

(15) Nottinghamshire County Council. Core offer of children's centres. See: childrenstrust/childrenscentres/coreofferofchildrenscentres.htm (accessed 8 April 2010).

(16) NHS Nottinghamshire County. Incredible mouths. Available at: healthy-living-advice/oral-health/262-incrediblemouths.html (accessed 24 March 2010).

(17) NHS Bassetlaw. NHS Bassetlaw strategic plan 2009 to 2014. Retford: NHS Bassetlaw, 2010.

(18) Department of Health. Facing the future: a review of the role of health visitors. London: Department of Health, 2007.

Cathy Burke

Children's services manager (designated nurse), Bassetlaw Community Health

Vicky Waring

Child health manager, Bassetlaw Community Health

Frankie Cook

Service development manager, NHS Bassetlaw
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Author:Burke, Cathy; Waring, Vicky; Cook, Frankie
Publication:Community Practitioner
Geographic Code:4EUUK
Date:May 1, 2010
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