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Evolving care in Hertfordshire: A unified approach to family health

This case study delves into Hertfordshire's strategic integration of health visiting and family support services to optimise the Healthy Child Programme. It outlines initiatives aimed at strengthening mental health support from the antenatal period to school age, enhancing workforce development, and providing targeted care for children with SEND.

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Highlighting the link between services, the impact of innovative practices, and the role of academic partnerships in recruitment and retention, the study presents a model for collaborative and responsive family health service delivery.

The challenge

In Hertfordshire, Health Visiting (HV) and Family Support Services (FSS) collaborate to provide a broad range of services central to delivering the Healthy Child Programme. 

Health visiting teams focus on the children’s health and development while the family support services offer enhanced family wellbeing, also addressing wider social determinants of health. Together this is known locally as the Family Centre Service (FCS). While this framework creates a comprehensive support system for families across the region, there is scope for greater synergy between the services and their respective workforces for more optimal delivery. 

Promoting positive social and emotional health is one of the key aspects of the Healthy Child Programme. One of the key challenges locally is ensuring that both services work in harmony to identify, support, and refer mental health needs effectively from the antenatal period through to school age. Service teams also navigate a large, intricate landscape of rapidly changing demographics and complexities within the community, which requires a responsive approach; this can be further impacted by staffing challenges.

The recruitment and retention of a skilled workforce remains a national concern, prompting Hertfordshire to seek more innovative strategies. Further, to ensure timely and effective support for families with complex conditions for children with Special Educational Needs and Disabilities (SEND), there has been a need to develop specialised pathways and coordination roles. Hertfordshire’s teams are diligently working to implement these pathways.

The solution

In response to national workforce and recruitment challenges, Hertfordshire County Council and public health nursing are working with University of Hertfordshire to build working partnerships with student nurses currently in training. This would create a route to successfully place students into the service and retain or employ these students following qualification. They are also actively promoting nursing as a profession through school nurses within Years 11, 12 and 13 through talks and small campaigns with the aim of building the workforce.

An example of where the services are trying to align is the strong integration between midwifery, health visitors and family support workers to co-deliver antenatal programmes. This includes Preparing for Parenthood classes for expectant parents as well as Pregnancy Circles (currently a pilot), which means families can access all their antenatal care in one place.

Further, Hertfordshire’s SEND health visiting leads work with the FSS SEND coordinators, which is a collaborative and active effort to integrate teams and promote good practice. FSS SEND coordinators work with families to provide early support and navigation through the system and enable the SEND health visitors to have the capacity to provide more specialist support. SEND health visitors hold smaller caseloads supporting up to 20 complex families acting as system navigators linking them into other health services.

If any emerging needs are picked up during developmental reviews, such as speech and language issues which are facilitated through ELIM, the leads can refer directly to paediatricians, speech and language therapy and offer to directly work with the family. This includes supporting the transition process into school. SEND health visiting leads sit on the Institute of Health Visiting (IHV) Advisory Group and have both a voice and influence in parliament and have played a vital role in supporting and developing local SEND development pathways for families.

To identify and support family mental health needs (one of the many important aspects of the Healthy Child Programme), both service teams within the FCS framework are jointly delivering a number of initiatives and support packages:

  • Both the public health nursing team and family support service are fully trained in Mental Health First Aid and are able to recognise early and signpost mental health needs, referring to the perinatal community team and other relevant services where required.
  • The health visiting service is piloting extending mental health screening to fathers as part of the 6–8-week postnatal check. Using well established screening tools, PHQ-9 and GAD-7, parents are offered tailored support and referrals depending on screening outcomes.
  • As good mental health begins in early infancy, through nurturing the parent-infant relationship, families are offered sessions on bonding, setting boundaries, parenting skills and attachment. Provisions begin from the antenatal period to six weeks, through to school.
  • The service partners with Petals to provide support for families that have experienced loss, stillbirth or neonatal. This links into CONI, Hertfordshire’s Care Of Next Infant support service.
  • Hertfordshire have also implemented the Becoming Dad program. Co-led by the early years and health visiting teams, it focuses on engaging fathers earlier. This has helped recognise that the current approach does not significantly involve fathers and helps in building attachments and supporting long term mental wellbeing.

Also delivered in an integrated way is the local infant feeding offer, where the FCS is a major contributor. Hertfordshire is a breastfeeding friendly initiative county and gold accredited in delivering breastfeeding support in line with UNICEF protocols and guidance. A local councillor has recently agreed to be a breastfeeding champion strengthening messaging further. Specialist health visitors run dedicated clinics and an array of support is available to support women including a free of charge breast pump loan service for mothers needing the support.

The impact

The pilot programme for parental mental health screening in the 6–8-week check has been well-received and particularly impactful in recognising and supporting fathers' mental health. During the pilot, 38% of dads were absent during the HV appointments, but of those present, 93% accepted emotional wellbeing screening. There is further work to be done to reach those fathers not attending appointments, to ensure the programme is addressing health inequalities.

The establishment of specialised pathways and the role of FSS and health visiting SEND care coordinators for families with complex needs or children with SEND has improved early intervention and support.

The team are also realising the benefits of building relationships with University of Hertfordshire with over 90% of recent student placements being retained post qualification. The team are looking at continuing this approach, also engaging with local schools to support pathways into the profession. 

How is the new approach being sustained?

For Hertfordshire, sustainability rests on focusing on innovation, service integration, workforce development and being fully responsive to community needs. There is a clear direction around aligning health visiting and family support services which includes efforts to marry up procurement timescales and service delivery models so there is a unified approach to care. 

Hertfordshire acknowledges rapidly changing demographics and rising levels of need and complexity in the population and the need for the new service to adapt and modernise. There is ongoing work around building up the perceived role of public health nursing in broader health and social care ecosystems and the approach to sustaining their services includes a focus on data-driven decision-making and the adoption of evidence-based practices.

Lessons learned

  • The partnership between providers and council leads is key and there has to be trust and communication along with shared value and direction.
  • It is vital that the provider-commissioning framework takes on a system-partnership arrangement and there are clear channels for information sharing.
  • Providers should be seen as partners and be bought into conversations early for cohesive strategy building.
  • There is still work to be done around how public health nursing is positioned in the system and the role their frontline experience plays in shaping services.


Aideen Dunne

[email protected]

Public Health Consultant

Hertfordshire County Council

Nicola Brown

[email protected] 

Assistant Director for Universal Children's Services.

Hertfordshire Community NHS Trust