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Memorandum submitted by The Royal College of Midwives (RCM)
1. The
Royal College of Midwives (RCM) is the trade union and professional
organisation that represents the vast majority of practising midwives in the
2. This submission focuses on the role of midwives in children's centres and their role in the delivery of maternity services. This submission has been prepared with the input from our members (including consultant midwives, community midwives and Heads of Midwifery), many of whom have either worked directly as a midwife in children's centres, or have worked in partnerships with these services.
Executive Summary 3. The RCM strongly supports the use of Sure Start Children's Centre to delivery maternity services. On the basis of advice from our members, it appears that such centres are able to deliver improved quality of care, particularly for those less likely to access mainstream services.
4. However, whilst we are supportive of these services and note the array of anecdotal evidence, we would recommend further formal evaluation of children's centre maternity services be included as part of the broader evaluation of Sure Start that is currently underway.[1] This should ensure that the centres are being implemented in the cost-effective way and are targeted appropriately.
The range and effectiveness of services provided by children's centres 5. The range of health services delivered from a children's centre vary depending on local needs and the existing configuration of services. Children's centres practice guidance - issued jointly by the Departments of Health and Education[2] - clearly states an expectation that maternity services and other parenting support services should be delivered from children's centres, especially in more deprived areas. In addition to general antenatal and postnatal services, the guidance suggests that children's centres could provide: well baby clinics or cafes; parentcraft classes; immunisation sessions; smoking cessation support; healthy eating in pregnancy and baby massage.
6. Healthy lives, brighter futures, produced by the Department of Children, Schools and Families (successor to the Department of Education) and the Department of Health in February 2009,[3] advocates a strengthened role for children's centres as part of a joint strategy for improving children and young people's health and providing parents with easily accessible support from pregnancy onwards. Particular emphasis is given to the role children's centres can play in improving support to families who have found it difficult to access traditional services. In the context of maternity care, specific proposals for strengthening the role of children's centres include: § Further improving antenatal and postnatal support for fathers, particularly those from the most vulnerable groups. § Testing a new Antenatal Education and Preparation for Parenthood Programme in a variety of settings, including children's centres. The programme will seek to improve access to high quality antenatal education and support to help prepare parents from early pregnancy onwards. § A strengthened focus on breastfeeding support delivered through children's centres, including: training for frontline staff to promote and support breastfeeding; the establishment of peer support groups and the provision of accessible and timely advice to mothers. § More help for pregnant women and mothers to give up smoking, or wider substance misuse. This will include supporting children's centres to host NHS Stop Smoking Services for mothers and fathers and encouraging closer working between substance misuse treatment services and maternity services.
7. In practice, information from our members indicates the range of maternity-related services provided by children's centres varies significantly, with some able to provide services such as aquanatal classes, breastfeeding drop-in sessions, pamper evenings, TENS loan scheme, and book loan service, as well as more traditional antenatal and postnatal services. Attachment 1 includes two case studies that have been submitted by one of our members to illustrate their experience of service delivery in a children's centre.
8. Beyond maternity care, many children's centres offer a range of activities for children and their families, including speech and language development, broader parenting skills, educational attainment and routes back into employment supported by links to agencies such as Job Centre Plus. In the experience of our members, these have been found to be effective, although there is not always sufficient data or information available to evidence such outcomes.
9. However, whilst some children's centres are able to provide a wide range of services, limitations such as access to rooms and space for IT equipment can inhibit what is able to be offered. The physical size of centres has also been anecdotally given as practical limitation to the range of services available. The actual location of centres can also limit access to, and use of, services, which in turn may inhibit the development of different services.
10. The effectiveness of maternity services through Sure Start local programmes was evaluated in 2005,[4] as part of the ongoing National Evaluation of Sure Start being conducted by the Institute for the Study of Children, Families and Social Issues at Birkbeck University of London. Whilst this study predates the full rollout of Sure Start children's centres, it is understood that children's centres were designed to build upon the implementation of the Sure Start Local programme.[5] Given there is little formal evaluation of the delivery of maternity services through children's centres, this earlier evaluation is the main evidence that has been gathered on the effectiveness of maternity service delivery through the Sure Start initiative. We also notes that many early centres were purpose designed and had space for midwives. Inc ontrast, our understanding is that whilst these earlier ones have had suitable space, other later ones have been adapted from existing premises, meaning that they are less likely to have room, thus constraining the scope of maternity services which can be offered.
11. The 2005 Evaluation report found that around one third of Sure Start local programmes had enhanced existing maternity services and created new services. This included some programmes introducing additional services that supplemented the care provided by mainstream staff, and others introducing caseload services, which provided full antenatal and postnatal care to all or some of the women within a Sure Start catchment area. The evaluation found that effective development of maternity services depended upon the availability of new resources (including midwifery time, venues and equipment), the involvement of mainstream stakeholders, community consultation and support with the broader sure start local program for maternity services to be a gateway for sure start.
12. This evaluation highlights the value of maternity services, and indeed reflects the on-the-ground experience of many of our members with children's centres. However, given children's centres have now been embedded in communities for a number of years, we would strongly support a formal evaluation of the effectiveness of children's centre maternity services, as delivered since 2005.
Access by those most in need 13. The 2005 evaluation of maternity services delivered through Sure Start local programmes found that access to services was improved on three levels: § identifying and making contact with pregnant women § creating accessible and flexible local services § providing support for women to access existing mainstream services.[6]
14. These findings appear to reflect the current experiences of many midwives, both working within and with children's centres.
15. In terms of what can improve access, the delivery of more accessible services appears to be linked to activities and services being based on the needs of the local population. RCM members have noted that such activities are well attended and are also often facilitate effective referral pathways for other services and agencies.
16. Children's centres also appear to provide an opportunity for greater innovation in service delivery - by facilitating the development of alternative models of care, as well as more diverse approaches and locations. This in turn appears to have meant that some women who otherwise would not be accessing care are able to receive maternity services, and to be referred to other services unrelated to their pregnancy. Timing has also been found to improve accessibility, with the availability of services in some centres being shifted outside standard clinical hours to evenings and/or weekends, as well as the introduction of more informal drop-in sessions, rather than strictly structured appointments.
17. Anecdotal evidence from out members indicates that the integrated models of care used by children's centres are working and are delivering better outcomes for families who use the. In particular, members have noted that vulnerable women do access services, especially the one-to-one Sure Start midwifery support service (where offered), which has been found to then often lead to access to other Sure Start services and support.
18. However, whilst there are such benefits, Heads of Midwifery and Consultant midwives from a number of different parts of the country have indicated that there is still the need for further work to ensure that services reach those most in need.
19. A key part of this appears to be making sure that children's centres reflect local need and are integrated into the local community. As suggested by one consultant midwife, the degree of access will often depend upon how integrated a children's centre is to the local community, and where it is located. Being integrated into the community can allow 'word of mouth' to spread about a centre and its services, making it more successful and accessible.
Multi-agency partnerships and linkages with mainstream services 20. The general experience of our members is that the children's centres have facilitated improved linkages between agencies, as well as between targeted and mainstream maternity services. The models of care being promoted through children's centres have facilitated more integrated working, particularly between health and social care, which can result in more effective delivery of services, as well as a greater understanding of each others role. Relationships between health services and the children's centres have created a more integrated 'working together' approach, resulting in improved communication that enables greater support for families.
21. In terms of linkages to mainstream services, a key way in which this is occurring, is through the secondment of midwives from mainstream services to Children's Centres, as it provides a natural join between services. In some cases, mainstream midwives also use children's centres as an alternative service delivery location, with one example being the delivery of parentcraft sessions from children's centres by mainstream midwives, rather than by just those attached to the centre. Other benefits which our members have noted include improving communication and understanding around the purpose of children's centres, sign posting opportunities, creative use of their space and services for pregnant women, and improved accessibility and visibility of health staff for families.
22. These findings are also supported in the 2005 evaluation,[7] which found that a key factor in improving relationships between maternity services at children's centres and mainstream services included maternity staff working for both sure start programmes and mainstreams services. Other factors found in the evaluation included: § relationship being established over time; § sure start programmes lightening the workload of mainstream staff; and § good communication.
23. In the context of linked up working, one concern which the RCM is aware of is that many of children's centres are not set up to accommodate clinical work, which is a large part of what the midwifery and maternity care. In order to avoid fragmentation of care , and to facilitate even greater continuity of care, consideration needs to be given to the establishment of further clinical space within existing centres, and the inclusion of such space upfront in future centres.
Sustainability and value for money 24. There is only limited information available regarding the cost-effectiveness of maternity services within children's centres. Communications from our members indicate that whilst it appears that services are providing value for money (and have improved in this respect as the services have developed), there is little in the way of robust documentation to evidence this.
25. The 2005 evaluation of Sure Start local programmes equally stated that its assessment was primarily based on qualitative rather than quantitative evidence. This would suggest that there is a distinct need for further cost-effectiveness studies, so that these findings can be considered in conjunction with the positive qualitative outcomes which appear to result from this service model.
26. An area around which our members have expressed concern is ensuring the longevity of the children's centre approach. As stated by one member, a key difficulty is translating the long term potential benefits into outcomes that are meaningful to an acute trust. Given the current financial pressures also facing trusts, there is some concern that funding for posts which are outside of core services may not be provided, or not renewed. This could inhibit the innovative and alternative approaches to maternity care which appears to be central to the integrated children's centre model, as well as remove some of the key linkages that have been established between children's centres and mainstream services, such as those provided by seconded midwifery staff.
October 2009
ATTACHMENT 1
Case Study A
Family A received a Sure Start visit from one of the Sure Start Midwives. Family A consisted of a mother (Amanda) and her 3 year old son. Amanda was pregnant (hence Sure Start visit from Midwife), and had a partner who didn't live with her. During the visit it was identified that the current house she was living in (had lived there for 5 weeks) was the first permanent home for herself and her son for the past 2 years. Previously Amanda had been living in hostels as she has been fleeing domestic violence (perpetrator - previous partner/ Son's father). This was discussed at length and it soon became apparent that Amanda had not received any support from any agencies and as a result was feeling very isolated and depressed and ws reluctant to leave the house with her son. 1:1 midwifery support was offered and accepted. Referal to counselling and right from the start project was offered and accepted. A further visit was arranged for 1 week. During the next visit a Marac assessment was completed and Amanda scored high which indicated that she was at high risk of serious injury as a result of domestic violence. A Marac referal was made with Amanda's permission to enable the right support to be put in place for Amanda. A further visit was arranged for 1 week. Amanda was seen at home again and had a visit from a 'right from the start' project worker and had received contact from an independent domestice violence advocate. The volunter from 'right from the start' has arranged to 'buddy' Amanda to various play sessions with her son (Amanda has never attended a play group with her son before) and attend the antenatal projects with her. The Sure Start Midwife asked Amanda how she felt things were going and Amanda replied, ' I feel like my life is being turned around, just because someone has really listened to me and is helping me. No-one has ever helped me before.'
Summary
Amanda was receiving mainstream care prior to a Sure Start Visit and had not disclosed how she was feeling or her history of domestic violence. She has only been known to the Midwifery project for two weeks. This case study is a typical example of a Sure Start visit to a vulnerable family. Families often disclose issues/ difficulties when seen in their own environment and offered 1:1 midwifery care. The Sure Start Midwife often becomes the co-ordinator of the families care during and after pregnancy, providing a link between agencies which is often missing in main stream care.
Case Study B
Family B received a routine visit from one of the Sure Start Midwives. This family consisted of the mother (Sam), the father and a 5 year old son. During this visit several pregnancy issues were discussed that had been raised several times during routine mainstream antenatal appointments. Although this family did not need 1:1 care, some 8 weeks later Sam remains in touch with the Sure Start Midwife who has liaised with several agencies on Sam's behalf to facilitate contact with relevant professionals to help alleviate Sam's pregnancy issues. Sam also highlighted in the Sure Start Visit that she had attended the antenatal projects during her last pregnancy (5 years ago), following the last home visit from the Sure Start Midwife. She highlighted that as a result of attending these projects she became friends with 7 other mothers of whom she attended most of the other Sure Start projects with postnatally. Sam still meets with the other mothers and their children weekly 5 years on. Sam stated that she felt she 'wouldn't have coped' without the support from all the friends she had made through accessing the Sure Start Projects. Sam currently attends all the midwifery projects during her current pregnancy.
Summary
Case study B highlights that the contact made by the midwifery project during pregnancy does lead to the accessing of services and the facitilitation of 'friendships' by bringing the community together. Case study B also highlights that families that do not need 1:1 care often turn to the Sure Start Midwives for support with pregnancy issues, especially if they are attending the Projects.
[1] See National Evaluation of Sure Start project: http://www.ness.bbk.ac.uk/ [2] Department of Education, Department of Health (2006) Sure Start Children's Centres Practice
Guidance, [3] Department for Children, Schools and Families,
Department of Health (2009) Healthy
lives, brighter futures: the strategy for children and young people's health,
[4] Kurtz Z, McLeish J, Arora A, Ball M and Members of the NESS Implementation Study Team (2005) Maternity Service Provision in the First Four Rounds of Sue Start Local Programmes, National Evaluation of Sure Start (NESS), Birkbeck University of London, November 2005, Research Report NESS/2005/FR/012 [5] Department of Children, Schools and Families (2009) Sure Start Children's Centres - online at: http://www.dcsf.gov.uk/everychildmatters/earlyyears/surestart/whatsurestartdoes/ [6] Kurtz Z, McLeish J, Arora A, Ball M and Members of the NESS Implementation Study Team (2005) Maternity Service Provision in the First Four Rounds of Sue Start Local Programmes, National Evaluation of Sure Start (NESS), Birkbeck University of London, November 2005, Research Report NESS/2005/FR/012 [7] Kurtz Z, McLeish J, Arora A, Ball M and Members of the NESS Implementation Study Team (2005) Maternity Service Provision in the First Four Rounds of Sue Start Local Programmes, National Evaluation of Sure Start (NESS), Birkbeck University of London, November 2005, Research Report NESS/2005/FR/012 |