Start Well, Stockport: early childhood services case example
This case example is part of EIF’s work to understand different approaches local areas are taking to providing maternity and early years services through community venues such as family centres and hubs.
Stockport was one of 14 local areas that took part in EIF’s 2020 review of contemporary practice in early childhood provision.
Find out more about our series of case examples.
Stockport is located in the south-east of the Greater Manchester city region, between the city of Manchester and the Peak District national park. Stockport is a large town with a busy central retail area, many district centres, and many local and international businesses.
According to the Office for National Statistics (ONS) 2017 mid-year estimates, around 291,000 people live in Stockport, of whom 21.6% (62,900) are aged 0–17 and 20% are aged 65 year or over.
The 2015 index of multiple deprivation ranks Stockport as having average levels of deprivation on a national scale. However, there is considerable polarisation within Stockport, between very affluent areas in the south and east of the borough and significantly deprived areas in the north and centre of Stockport.
Start Well: Stockport’s early childhood services model
Stockport’s early childhood services are incorporated into their ‘Start Well’ model, which was established in April 2018. The model has evolved over time to take account of a review of the use of children’s centres and more recently the integration of health visiting and early years. Start Well now brings together health visiting, children’s centres, early years and childcare, and portage teams to create greater integration in the early years, including for children with special educational needs and disabilities. Midwifery is also closely aligned to Start Well, driven by a focus on continuity of care.
The aim of the Start Well model has been to remove duplication, improve access to services and give flexibility in response to demand, targeting resources according need.
Locality working is a key part of the model, working in partnership with communities, schools and early years settings. Start Well builds on the Greater Manchester Early Years Delivery Model and the 8 Stage Assessment pathway, which is underpinned by the Healthy Child Programme. It is driven by further integration of early years services that were traditionally delivered by practitioners with different professional backgrounds and organisational cultures. The Start Well model has an ethos of restorative practice, which supports practitioner confidence and encourages creative solutions.
Start Well focuses on school readiness, achieved by giving children the best start in life and reducing health and development inequalities. Work to enhance school readiness starts at pre-conception and continues through early infancy. All services and partners involved in working with children and families have a part to play in promoting school readiness for children.
Delivery of the model
The Start Well model is embedded within ‘Stockport Family’, which is an integrated approach bringing together all 0–19 years services (to 25 years for SEND and care leavers). There are four localities within Stockport and each has a number of Start Well health visiting and early years teams. Each locality has a lead who is from a health or early years specialism and who is employed by the NHS foundation trust or the local authority.
There are Start Well hubs in Brinnington and Adswood, and these two sites remain designated with the Department for Education as Sure Start children’s centres. There are also three Start Well satellites (Central, Belmont and Reddish) which support staff co-location and provide a venue for the delivery of some interventions. These locations were identified as key areas of disadvantage.
The Stockport Family system is described as “feeling like true integration”. It has created a stronger understanding of roles and pooling of knowledge. Start Well team members may be employed by the NHS foundation trust or the local authority, but they function as one integrated team. There is individual child-level data-sharing between the NHS foundation trust and local authority, supported by a data protection impact assessment, which has strengthened trust between the local authority and foundation trust.
Health visitors are key to understanding need. The use of health visitor data extends the reach of services by identifying the most vulnerable children. The data also helps to target resources much more effectively.
Initiation and design of the early childhood services model
In 2014 a review of the system was undertaken not only to make savings but also to design a system that would lead to improved outcomes for children and families. The first phase of integration was of health visiting, early years and children’s centres. Before this, the services had had a partnership working relationship but not true integration. Designing this new model of integration included the following components.
Start Well roles
One job description was created for all community nursery nurses and children’s centre development workers, regardless of whether they were employed by the NHS foundation trust or local authority. There had previously been a range of different job titles, but families didn’t understand the differences and just wanted one key worker. The new role of early years worker sits in the Start Well health visiting and early years team.
The role of team leader was created with professionals from a variety of backgrounds to bring together different skill sets. This included experience in health visiting, children’s centres and family support. The third role is that of service lead, who brings expertise in their own specialism to the system while managing staff in Start Well teams employed by different organisations.
Following the workforce changes, Stockport began to streamline service delivery. There had been a lot of duplication and there needed to be further development of resource allocation to ensure equality of outcomes. They started to target resources at areas of deprivation and where school readiness outcomes were poor.
It was recognised that recording activity data for children’s centres in a local authority information system wasn’t helpful when health visitors were seeing and recording information about families in an NHS foundation trust system. Therefore, it was decided to stop recording children’s centre activity data. Through the health visitor assessment, there was a clearer understanding of vulnerability, and the Greater Manchester Early Years Delivery Model and 8 Stage Assessment pathway supported standardised assessment and intervention points. All staff within the Start Well team now record on the same electronic patient record system as part of the integrated team approach.
The next step was to look at the use of buildings. In this new emerging model, buildings were not the most important element. What mattered was the relational approach (interacting or communicating with others in a way that embodies core values such as respect, inclusiveness, honesty, compassion, cooperation and humility) and working with families in a variety of settings, but with an increased focus on home visiting. Some buildings were still needed for group work and co-location of staff, but there was a shift away from delivering everything from buildings. Some people did feel like they had lost their children’s centre but hadn’t lost their service offer.
Focus then shifted to workforce development, especially around working with families in the home. A core element of this was embedding the ethos of restorative practice and Solihull Approaches. This shared culture meant that everyone now works and behaves in ways that mean all are listened to and are open to constructive challenge. It has resulted in a shared language across the local authority and NHS, and this ethos also underpins work with families.
Implementing the model
The new model was implemented through a ‘design by doing’ approach. A “blueprint wasn’t thrown on the table” – they had a vision and an idea, and shaped it as they went along. There were challenging conversations, but those who were implementing the model tried to work in a restorative way, and felt that that helped. The changes did not sit comfortably with some people, as they didn’t know what the end result was going to look like and they were being challenged to think differently and be creative. It was, and still is, difficult for some people. This has been one of the biggest challenges, and inevitably it has resulted in some staff turnover.
The shared vision, aims and the relational way of working was the guide. Implementing the model highlighted the importance of negotiation and compromise, as it brought together two different cultures from the NHS foundation trust and local authority. It took time to build trust between different professional groups: for example, there was a resistance to being managed by someone who was ‘not one of us’. An important message was “it’s a salad, not a soup”: a mix of expertise where individuals do not lose their professional status and role. Culture change has been achieved through “doing a lot of listening and needing to change things as we went along”.
Data-sharing has improved over the years of implementation. The NHS foundation trust agreed to share child-level data with the local authority, which added to the integration of teams. Agreement to share data was achieved by slowly building relationships and trust between the NHS foundation trust and local authority, and a continual focus on the reason for sharing: to improve outcomes for families. A data protection impact assessment is used as a reference when anxieties about data-sharing emerge.
Over the past year, in response to Covid-19, Stockport have further enhanced their model. The Start Well strategy has been refreshed with a refined vision and priorities, and is now aligned to the ‘Best Beginnings’ report from the Children’s Commissioner, adopting the ‘5 key essentials’. Pathways have been quality-assured to ensure that additional needs are identified as early as possible and that interventions are underpinned by a robust evidence base. Work is underway on a shared understanding of school readiness and creating a shared responsibility with all partners.
The Covid pandemic has also meant moving to a more digital offer, and parents asked for ‘a virtual front door’ to bring information into one place – so Stockport have created an online portal at https://www.startwellstockport.co.uk/.
Use of evidence
Stockport’s integrated model has been built on a more effective understanding of population need and vulnerability, using the universal family data held by the health visiting service. This has improved how resources are targeted, particularly the Start Well offer. This population data is helping Stockport to understand how to enhance their offer as the complexity of family needs increases.
Stockport has also used evidence-based interventions to plug some of the gaps left over the past few years due to funding reductions. EPEC (Empowering Parents Empowering Communities), for example, was introduced because locally delivered parenting programmes had become much more targeted and were felt to be stigmatising, which made it more difficult to work with some parents. EPEC was introduced as a universal offer but only made available in particular geographical areas. In the beginning, Start Well teams found it difficult to understand how EPEC worked. They were so used to working with specific targeted families that at first they suggested lists of these families, rather than understanding that this was a universal offer in a specific geographical area. The universal model of EPEC has been important in reducing stigma and restoring trust following changes and reductions in some other universal services.
Delivering EPEC has also shown Stockport the power of parents as partners and leaders, which has supported thinking about Stockport’s overall parenting strategy and community co-production.
- Shared vision and belief: The people implementing the model had a ‘can-do attitude’ and a shared belief in ‘not stopping until they get there’. Previously, Stockport found it harder to deal with challenges which meant that progress could be held up, but now they keep going because of the good relationships and integration across the system. This is supported by keeping ‘drip-feeding’ messages about the vision and model within the system. It is also helped by key leaders understanding the role and importance of different services; for example, the Director of Children’s Services is the commissioner for public health nursing.
- Workforce development: The creation of a robust workforce development plan, which included a workforce review of roles across agencies, bringing together different skills sets and professional disciplines, was a really important enabler for Stockport. Having a minimum specification for all team members’ development is key. Everyone has done some sort of restorative practice training, and there is now an in-house workforce development team. Having a good restorative supervision model helps to build resilience, and particularly helps people to cope with change. The Solihull Approach is used to promote emotional health and wellbeing, and to support relational-based practice. Co-location is seen as helpful but “isn’t the be-all and end-all of integration”. Part of ongoing workforce development are ‘learning circles’ – these provide opportunities to understand each other’s roles, which can be difficult when working in big organisations. The greater understanding helps to build respect and reduce conflict.
- Communications: Using clear branding for Stockport Family and Start Well was found to be very important, along with clear messaging about the services.
Barriers and challenges
- Pace of work: Constantly working at pace means that it feels like there is no time for consolidation. The urge to work quickly is felt to be in part due to financial pressures and in part due to not getting it right yet for children’s and families. To address this, Stockport are currently working with academics in Greater Manchester to understand what leaders need to be able to work at this pace.
- Savings requirement: Funding reductions were a driver for change, but it was also felt that better integration was required regardless. The new model is described as being more streamlined, resulting in less waste, less duplication and better information-sharing.