In 2023 through to 2024, we worked with Stockport Metropolitan Borough Council, Greater Manchester Combined Authority and Stockport NHS Foundation Trust to improve collaboration and coordination between health visitors and midwives - one of the biggest barriers to providing antenatal care to families.  We co-designed a potential solution - the joint-visit service innovation - which took a relational approach to build trust between practitioners and with families, gain insights into the parents’ priorities and elevate the voice of the unborn baby in planning and decision making. 

The joint visit innovation is part of a wider programme of work, the Enhanced Maternity Pathway, which takes a holistic view of what families need and how multiple Stockport services can work more closely to better support families early on. We know that the antenatal period of pregnancy and the time shortly after a baby is born are critical for a baby’s development and setting children up for the best start in life. Parents are balancing many needs like taking care of themselves, their families and their growing baby, and so it is especially important to build trusting relationships early on with the practitioners and services that can help support them. 

The joint-visit service innovation involves:

• an in-person visit where parents meet with their named midwife and named health visitor at the same time when they are between 20 and 25 weeks pregnant 
• practitioners using the My World Assessment, which we’ve adapted from Scotland unborn babies, and the Risk and Resilience Matrix to understand the holistic picture of the family’s situation and factors that impact the baby’s development 
• using motivational interviewing techniques during the visit to draw out the parents’ priorities, rather than a tick box exercise that practitioners need to complete. 
• joint planning with practitioners and families that clearly outlines the support offered and next steps through the pregnancy and after the baby arrives. 

Once we were confident in how the visit should take place, we needed to test it to learn if it could work in practice with families. Beginning in October 2023, we piloted the joint visit in three areas of Stockport: Adswood, Brinnington and Offerton. We set an ambitious target of conducting 45 visits in two months. Our objectives for the pilot were to understand:

• which kind and style of training is needed for practitioners to feel confident conducting joint visits with families
• through joint visiting, can we identify and reach families who would benefit most from closer practitioner collaboration
• is it possible for practitioners to carry out joint visits as we designed them, in terms of timing, location and approach
• which factors enable or hinder joint visits from happening.

This project links to our mission goals by:

• focusing on early intervention during pregnancy
• promoting innovative approaches to service delivery
• fostering collaboration between different professional groups
• using a design approach to test and learn through prototyping, piloting, and iterating our ideas to refine solutions. 

During the pilot, we conducted joint training for 23 practitioners. This involved designing information materials and handouts, examples of the types of visits practitioners might see, and practice examples for practitioners to try out on their own. Practitioners completed joint visits with 13 families of varying complexity. This was fewer than we had intended, but we learned there were many operational challenges that prevented more visits from happening. We developed multiple feedback mechanisms, including: 

• pre-and post-training surveys for health visitors and midwives
• individual practitioner interviews after each joint visit
• parent feedback calls with team leaders after their joint visit. 

We addressed operational challenges, such as calendar sharing between practitioners and developing how-to-guides and templates for easy reference when conducting joint visits. We worked with NHS Foundation Trust and Stockport Council Information Governance Teams to determine how to provide this information to health practitioners. 

After the pilot period ended, Nesta analysed the multiple forms of feedback and facilitated a workshop with practitioners and service leads to collectively make sense of what we learned. Together, we prioritised the steps to work through next. 

Our approach to piloting the joint service innovation allowed us to:

• iterate on the joint-visit concept in real-time to improve the experience for practitioners and for parents
• gather rich, qualitative data from multiple perspectives to understand what was going well and what we needed to improve on 
• better understand the complex system of delivering early-years interventions across multiple services so we can empathise and address the day-to-day realities of practitioners and service leaders.

Using a test-and-learn approach, we put our concept into practice, and learned more about how to implement service design in practice. The following themes were important lessons:

Parents liked meeting practitioners together. Parents had a better understanding of the roles of each practitioner, especially for health visitors who they most likely had not met yet. They had greater awareness and confidence in the support that was available and how they would access it, and appreciated not having to repeat information about their medical or social history. Parents appreciated meeting both practitioners together and felt listened to because they were able to raise their own concerns or priorities. 

Practitioners liked working together with families but spotted room for improvement. Practitioners overall liked the joint visit with families. They benefited from working together and sharing knowledge, which felt more supportive for families, especially for those with complex needs. Practitioners appreciated the more relaxed style of visits that happened earlier in pregnancy, so parents could fully engage in the conversation. However, they expressed frustration at some of the operational challenges and concern about their high caseloads.

Trying something new. Practitioners had varied past experience in conducting joint visits, but it was the first time they had done joint visiting in this way using the new assessment. The joint training gave practitioners knowledge and context for the visit, but needed to practise the skills to build their confidence. We needed to be comfortable setting an ambitious target for the number of joint visits and then embrace the lessons we learned, even when we didn’t meet our goal. 

Relationships between practitioners are both an outcome and enabler of effective joint visiting. Practitioners had different experiences working together before the pilot. The joint visit was useful for less experienced professionals to become comfortable working together, and where professionals had close pre-existing relationships they were able to build on each other’s strengths to support families. 

The ‘spirit of the visit’ was just as important as what happened during the joint visit. The joint visit was designed to take a more relaxed, conversational approach to building relationships with families. Instead of ticking boxes in a list, practitioners use tools like the Risk and Resilience Matrix and My World Triangle. Adapted from Scotland’s guidance on using the National Practical Model, they use this to openly discuss strengths and challenges the family faces. 

Key components of the joint visit include using:

• motivational interviewing practices to empower families to discuss their strengths and needs
• the My World Triangle to better understand what the unborn baby needs to grow and develop, what they need from the people who will care from them, and what they need from the wider world. 

Having a strong understanding of our theory of change and the purpose of the visit helped to maintain support for the visit, even when things were challenging. 

We are taking our learnings from the pilot phase of the project into year three of our Fairer Start Local partnership, where we will implement joint visiting across all midwifery and health visiting teams in Stockport. By improving coordination between health visitors and midwives, we can:

• provide more integrated, family-centred care
• identify and address concerns for a baby’s development earlier in pregnancy
• empower families to discuss their strengths and needs
• support service delivery to improve outcomes for children and families.