In 2023, Nesta’s Fairer Start Local partnership with Stockport Council looked at how innovation in the health visiting service could improve outcomes for disadvantaged children. Building on research from year one of the partnership, the health visiting team in Stockport felt there was scope to redesign their service to be even more attuned to the needs of disadvantaged parents. Areas with potential for improvement included identifying needs earlier, ensuring parents received the right level of support, engaging parents more effectively and reducing the need for parents to repeat conversations to both midwives and health visitors.

We set out to use Nesta’s design thinking expertise to prioritise problems to address, develop ideas for new solutions and to test a prototype for the solution. We took a test and learn approach in order to develop an on-the-ground service innovation with frontline practitioners that could improve outcomes in Stockport and beyond. 

This work began in February 2023 with a four-day design sprint bringing together services leaders in Stockport with Nesta’s fairer start mission team. Through a series of workshops, we guided attendees to move from six problem statements, through brainstorming and prioritisation, to settle on one specific idea with a broad outline of a solution to be developed. 

We moved through several phases of design and testing to develop the concept:

1. Partnership with purpose: initial problem identification and solution outline (February 2023)
2. Pragmatic co-production: detailed problem exploration and prototype development (Spring/Summer 2023)
3. Making it real: prototype testing and refinement (Autumn 2023)

From the outset, we applied principles, learning from design, and previous Nesta innovation partnerships to guide the project’s structure and relationships. 

We aimed to:

• start from a deep understanding of the problems we’re addressing
• ensure that we develop a partnership of equals
• create strong buy-in for any eventual solution through involvement of service leaders and frontline professionals
• use design-thinking methodology to move at pace from defining the problem to finding solutions, and building and testing a prototype.

In the first workshops, we set out a number of different problems that health visitors faced. We identified the following challenges:

• The existing patterns of visits and assessments may not be identifying need at the earliest opportunity. 
• Their assessment tools might miss important needs or might over-identify risks and assign families more support than they require.
• Practitioners find it difficult to balance the needs of universal and targeted families who require longer or more frequent visits as well as more time-consuming record keeping.
• Some of Stockport’s Start Well local integrated teams did not have the ideal skill mix for practitioners, including safeguarding, confidence holding risk and community engagement. 
• Health visiting and midwifery teams do not work closely enough together, which leads to duplicating work and missing information-sharing opportunities that could help to better identify family’s needs. 

The potential solutions we explored for these problems included creating specialised teams for complex caseloads, improving the training offer to build practitioners skill mix, changing the schedule of visits and assessments, or increasing administrative support for record keeping.

The problem that had the greatest opportunity for improvement was limited integration between health visiting and midwifery teams. The initial solution was to introduce a joint visit between the health visitor and midwife, aiming to reduce workload overlap for professionals and reduce the burden on parents by giving greater continuity of care. Then we developed a detailed description of the problem to solve and a summary of our ideas for the solution, which we used in collaborative design sprints.

We gathered frontline practitioners, service leaders, and community representatives to build an initial prototype. To learn more about how services are delivered, and why the lack of joined-up working was a problem for practitioners and parents, we shadowed their sessions in a health centre. Our focus was to ensure the practitioners were actively involved in developing the solution by having workshops and frequent feedback sessions with health visitors and midwives. 

We asked health professionals to put themselves in the shoes of parents in order to see the service from their perspective, and we involved community representatives from the Maternity Voices Partnership. We also interviewed parents at a baby and toddler group. Working in this way helped us incorporate parent and carer voices alongside frontline professionals and allowed us to consider different perspectives on what would work best for families.

In Autumn 2023, we prototyped the joint-visit innovation to understand how it could practically be implemented. We began with short, quick ‘experience prototypes’, getting practitioners to try out different styles of visits. We experimented with the information provided to practitioners beforehand, the use of checklists or topic guides, ways to discuss the visit’s purpose with parents, and conversational styles with parents. 

By having different practitioners try out the visit, and observe how it went, we tested our assumptions about what a joint visit might look, sound and feel like. We learned that focusing on understanding a parent's concerns, rather than jumping to finding immediate solutions, helps build trust with families. Referencing the baby, or the ‘bump’, directly helped start conversations about early attachment and opened up the conversation to discuss additional factors impacting the parent and unborn baby’s wellbeing. Practitioners, particularly those with less experience, found it helpful to have a general structure and prompts for discussion, but didn’t want the visit to become a ‘tick box’ exercise.

As a result of this work, we developed:

• a high level of engagement, from health visitors and midwives through to strategic decision makers. People were excited about the depth and speed of progress we made and felt like the joint visit was “the right thing to do” for families in Stockport. Building support for our project early on has meant practitioners have been able to meaningfully shape what a joint visit is and how it is carried out. We could easily receive feedback from different people across the Council and NHS Foundation Trust, and senior leaders are aware of and support what we are doing. 
• a clearer articulation of the needs and challenges for the joint health visiting and midwifery visit. The perspective of parents, midwives and health visitors gives us a strong foundation and reasons for why we are designing a joint visit and what objectives we need to achieve. 
• a storyboard describing the process for the joint visit. We have changed and adapted this document overtime, but it is a short, quick way to describe how a visit should take place and the activities that will help us meet our objectives. 
• an understanding of the key logistical issues that we need to address to ensure joint visits are possible. This includes when and where visits should happen and how families’ records and information are shared between health visitors and midwives, and how joint plans are made with families. Moving forward, we must meet the operational and logistical needs of practitioners to ensure the joint visiting process is easy to understand and conduct. 
• an understanding of the key ingredients for the joint-visit innovation in order to have the desired outcomes:
  • A focus on relationship building.
  • Appropriate and timely information provision.
  • Consistent shared assessment.
  • A clearly communicated joint plan. 

Our test-and-learn approach and pragmatic co-production have helped us design a new way of service delivery in Stockport, by building trust with practitioners and strategic decision-makers. Now we know much more about how services are delivered and the good solutions needed to improve relationships with families and between practitioners. 

We are taking these findings forward by putting the joint-visit service innovation into practice. In Winter 2023, we are piloting the joint visit in a few areas before we roll it out across all of Stockport in 2024.