The Journal of the Community Practitioners’ and Health Visitors’ Association MAY 2017 VOLUME 90 / NO. 5

UNDER THE MICROSCOPE Antimicrobial resistance and public health

‘You have to bite’ Summer’s coming Immunisation MP Rachael Maskell on Promoting sun Why it needs to stay fi ghting against cuts safety to families high on the agenda

communitypractitioner.com | unitetheunion.org/cphva

01 COVER FINAL.indd 1 27/04/2017 12:46 Get to know us better when it comes to safety

Here at JOHNSON’S®, we’re mums and dads too, and like you, we want what’s best and safest for our little ones. That’s why, for over 125 years, we’ve utilised the latest science to create safe, mild and HıHFWLYHEDE\SURGXFWV We have a 5-step safety assurance process which ensures our products are safe: 1. We are choosy Every supplier must meet our rigorous quality and safety standards 2. Every ingredient is assessed for safety (YHU\LQJUHGLHQWLVULJRURXVO\UHYLHZHGE\VFLHQWLIJFH[SHUWVWRHQVXUHLWPHHWVRUH[FHHGVWKH requirements for safe use 3. We go above and beyond with our ingredients and products Depending on the product, we work with dermatologists, ophthalmologists, paediatricians, midwives, and other specialists to help ensure clinical safety 4. We carefully assess how real customers use our products Hundreds of families test our products before they are ever placed on a shelf 5. When it comes to safety, we never rest We speak to thousands of parents, scientists, and regulators to remain vigilant and ensure every product meets our safety standards throughout its lifetime Because we care about every little baby.

For more information about our Safety and Care Commitment, please visit: www.safetyandcarecommitment.com We welcome any feedback, please email us at [email protected]

© Johnson & Johnson Ltd 2016 UK/JOB/16-8099

p02.CPMAY2017.indd 2 26/04/2017 11:32 Contents Volume 90 Number 5

EDITORIAL 5 Getting into gear NEWS 6 A look at the latest in public health 28 10 The most recent research from the professions

12 A juggling act OPINION 14 Unite head of health Sarah Carpenter on how the Pay Review Body’s report is at odds with the 1% pay rise

15 An initiative offering dementia patients comfort through music

16 York Central MP Rachael Maskell explains why public health nurses have a duty to stand up for their work

18 The Unite-CPHVA’s lobbying event in parliament

21 A retired health visitor shares her lessons learned 34 A project to improve LAST WORD clinical supervision in 48 Science writer Meredith FEATURES community nursing teams 22 Promoting sun safety to Wadman has a passion for 25 is bringing benefits to both vaccines and their impact children, young people patients and staff and families as the summer on public health months roll around 36 Professor of Child Public EVENTS Health Helen Bedford on 50 Useful dates for your diary 25 We offer tips on obtaining whether immunisation is funding to attend this year’s slipping down the health Unite-CPHVA conference visitor agenda

38 Tailoring early intervention in vulnerable families

46 A collaborative project in Somerset improving perinatal mental 15 health outcomes RESEARCH 40 A study exploring the 28 Lorna advantages and challenges COVER practitioners experience in Duckworth STORY 22 explores the the Solihull approach potential impact of antimicrobial 43 Using volunteers to resistance on public health support vulnerable families and how practitioners could can bring about great help tackle it benefits, this study finds

May 2017 Community Practitioner 3

3 .indd 3 27/04/2017 12:47 PROFESSIONALFOR HEALTHCARE USE ONLY PROFESSIONALFOR HEALTHCARE USE ONLY a aSTAR: STAR: AN AN EVIDENCE EVIDENCE--BASEDBASED APPROACHAPPRO TO TO THE THE MANAGEMENTMANAGEMENT OF OF INFANTINFANT REGURGITATIONREGU ATION

FunctionalFunctional gastrointestinal gastrointestinal disorders disorders PRESENTPRES IN (FGIDs)(FGIDs) are are an an under under recognised recognised andand N poorly managed group of digestive >50%>50% OF poorly managed group of digestive 1 symptomssymptoms and and feeding feeding problems problems11 INFANTSINFAN

WHATWHAT IS ISINFANT INFANT REGURGITATION? REGURGITATION?22 A normal physiologicalphysiological processprocess INFANT REGURGITATION Regurgitation is the that occurs in a Regurgitation is the that occurs in a passage of stomach developing infant gut passagecontent of up stomach the oesophagus developing infant gut PLACES A SIGNIFICANT Mouth contentand into up the the mouth oesophagus Mouth and into the mouth NFANTBURDEN REGURGITATION ON FAMILIES,

5HƮX[LVWKHSDVVDJH THE NHS AND THE 5HƮX[LVWKHSDVVDJHof stomach content PLACES A SIGNIFICANT Weak action of of stomach content Weak action of into the oesophagus ECONOMY ALIKE: lower oesophageal into the oesophagus lowersphincter oesophageal (valve at for BURDEN ON FAMILIES, sphinctertop of (valvestomach) at for Stomach The distressing levels of crying and disrupted top of stomach) 1 Duodenum Stomach THEfeeding canNHS cause serious AND anxiety THE for parents Stomach Duodenum Stomachcontents ECONOMY ALIKE: contentsleak back 'HVSLWHHYLGHQFHWRVXSSRUWƬUVWOLQH leakup backinto the without the presence nutritional management in bottle fed babies, oesophagus 4,6 up into the of other symptoms*3 use of infant alginate therapies remains high Pyloric sphincter (valve) oesophagus without the presence e distressing levels of crying and disrupted 3 of other symptoms* 1 Pyloric sphincter (valve) ding can cause serious anxiety for parents NHS England spent

INFANT REGURGITATION IS IN INFANTS WITH VOMITING OR REGURGITATION, 'HVSLWHHYLGHQFHWRVXSSRUWƬUVWOLQH FREQUENTLY CONFUSED WITH LOOK OUT FOR ‘RED FLAG’ SYMPTOMS WHICH MAY tritional£5.2m management in bottle fed babies, INFANT REGURGITATION- IS IN INFANTS WITH VOMITING OR REGURGITATION, 4 GASTRO OESOPHAGEAL SUGGEST DISORDERS OTHER THAN GOR, FOR EXAMPLE: in 2015 on infant alginate 4,6 FREQUENTLYREFLUX DISEASE CONFUSED (GORD WITH) WHICH LOOKO PROJECTILE OUT FOR VOMITING‘RED FLAG’ SYMPTOMS WHICH MAY of infant alginate therapies remains high 4 GASTROIS LESS-OESOPHAGEAL PREVALENT, MORE SUGGESTO BILE OR DISORDERS BLOOD STAINED OTHER VOMIT THAN GOR, FOR EXAMPLE: SUHVFULSWLRQVDQGWKLVƬJXUHLV ( ) O 6,7,8 REFLUXSERIOUS DISEASE AND MAYGORD REQUIRE WHICH PROJECTILEO FEEDING DIFFICULTIES VOMITING OR FALTERING GROWTH increasing by 10% year on year IS LESSSPECIALIST PREVALENT, REFERRAL MORE4,5 O BILEO APPEARING OR BLOOD UNWELL STAINED VOMIT SERIOUS AND MAY REQUIRE O FEEDING DIFFICULTIES OR FALTERING GROWTH HS England spent SPECIALIST REFERRAL4,5 O APPEARING UNWELL FOR BREASTFED BABIES Trained professional carry out a breastfeedingTra £5.2m assessment FORNATIONAL BREASTFED GUIDELINES BABIES n 2015 on infant alginate 4 Withbre persistent regurgitation, consider NATIONALRECOMMEND: GUIDELINES trialling alginate therapy for 1-2 weeks 4 Wit RECOMMEND: tria a STAR APPROACH Assess feeding history and TO TREATING reduce feed volume if excessive a STAR APPROACH for infant’s weight4 TOINFANT TREATING INFANTREGURGITATION Trial smaller, more frequent feeds (while maintaining an appropriate REGURGITATION total volume of daily feed)4

Trial a thickened formula (for example, containing rice starch, cornstarch, locust bean gum or carob bean gum)4

If the stepped-care approach is unsuccessful, stop the thickened formula and trial alginates for 1-2 weeks4

If alginates are successful continue use but stopping it at intervals to assess recovery4

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p04.CPMAY2017.indd 4 26/04/2017 11:35 EDITORIAL

Getting into gear Unite-CPHVA Existing Unite-CPHVA members with queries Welcome to the May issue of Community Practitioner. relating to their membership should contact 0845 850 4242 or see unitetheunion.org/ contact_us.aspx for further details. To join Unite-CPHVA, see Just days before going to press with this issue, yet another general unitetheunion.org election has been announced, which means yet again we will be Unite-CPHVA is based at 128 Theobald’s Road, London WC1X 8TN trudging along to the polling stations on 8 June. And after the 020 3371 2006 shock EU referendum result, many of us will be wondering whether Community Practitioner our vote will make a diff erence. Unite-CPHVA members receive the journal free But vote again we must, and it’s vitally important that we do. each month. Non-members and institutions may subscribe to the journal to receive it. With the snap election just a few weeks away, there’s little time for Non-member subscription rates the political parties to hit their campaign trails and already wildly Individual (UK) £125 ambitious – or unrealistic – policy promises are being made. Individual (rest of world) £145 Institution (UK) £145 As I write this, news has broken that Jeremy Corbyn has Institution (rest of world) £195 announced a Labour government would pay NHS staff more and end the widely contested Subscription enquiries may be made to tuition fees for student nurses and midwives. Indeed, three specifi c promises from the Community Practitioner subscriptions party set out to scrap the 1% pay cap to increase pay to a ‘sustainable level’ for NHS staff , to Redactive Publishing Ltd PO Box 35 reverse the end of student nursing and midwifery bursaries, and to impose tougher rules on Robertsbridge TN32 5WN safe staffi ng levels. t: 01580 883844 [email protected] Admirable pledges indeed, and the accompanying rhetoric is on point, with shadow The journal is published on behalf of health secretary Jon Ashworth declaring: ‘Enough is enough. What is bad for NHS staff is bad Unite-CPHVA by Redactive Media Group, for patients too.’ 17 Britton Street, London EC1M 5TP 020 7880 6200 Indeed, many of you took the unique opportunity to hear Mr Ashworth speak in the Editorial advisory board setting of parliament itself on 26 April, when Unite-CPHVA’s lobbying event took place. Obi Amadi, Surrinder Bains, Lucretia You can read more about this memorable afternoon on page 18 – it certainly represented a Baptiste, Louise Condon, Toity Deave, Barbara Evans, Gavin Fergie, Elaine signifi cant day for public health nurses, one on which hardworking healthcare professionals Haycock-Stuart, Brenda Poulton, took the time to stand up for valuable services like health visiting and school nursing, and Janet Taylor told MPs directly why they should be protected by ring-fenced funding and not cut in favour Editorial team of fi nancial savings. Emma Godfrey-Edwards, managing editor [email protected] And, as the snap election approaches, let’s harness this momentum and build on it, by Helen Bird, editor continuing to engage with the MPs seeking our votes and asking candidates directly what [email protected] 020 7324 2757 their party would do to invest in health visiting and school nursing services. The current Chloe Crisford, picture editor political climate arguably provides the ideal opportunity to have your voice heard. Nicholas Daley, designer Staying on a political theme, elsewhere in this issue on page 16 you’ll fi nd an interview Unite health sector officers with York Central MP and former Unite head of health Rachael Maskell, who reinforces the National officers: Sarah Carpenter and Colenzo Jarrett-Thorpe need to stand up and speak out during these uncertain times. And on page 14 your current Lead professional officers: Obi Amadi; Gavin head of health, Sarah Carpenter, highlights inconsistencies between the NHS Pay Review Fergie; Rosalind Godson; Dave Munday; Jane Beach; and Ethel Rodrigues Body’s report and the government’s decision to retain the 1% pay cap. Step forward Jeremy Corbyn, this could be your moment. Advertising queries Alex Edwards 020 7324 2735/[email protected] Production Jane Easterman 020 7880 6248/[email protected] Printed by Warners © 2017 Community Practitioners’ and Health Visitors’ Association ISSN 1462-2815 The views expressed do not necessarily represent those Helen Bird of the editor nor of Unite-CPHVA. Editor Paid advertisements in the journal do not imply endorsement of the products or services advertised.

May 2017 Community Practitioner 5

ditoia .indd 27/04/2017 12:4 NEWS ROUND-UP NEWS ROUND-UP A look at the latest in public health

Fears benefit cap will ‘push 200,000 more children into poverty’

New limits being imposed on benefi t child benefi t will remain unaff ected by payments could force 200,000 more children the changes. into poverty, campaigners fear. The latest data shows that 872,000 families Changes that came into force on 6 April with more than two children were claiming will see the payment of some benefi ts limited tax credits in 2014-15. to the fi rst two children in a family. In the same period, 65% were working UK public health They aff ect families who claim tax credits families and 68% had no more than and universal credit, which is set to replace three children. budgets are a tax credits by 2022. The researchers calculated that, based on ‘false economy’, The Child Poverty Action Group (CPAG) these fi gures, an additional 100,000 adults and Institute for Public Policy Research claim and 200,000 children could face poverty once research suggests some families will be almost £3000 per year the new rules are fully implemented. Recent cuts made to public health worse off under the changes. CPAG chief executive Alison Garnham budgets in the UK are set to cost the The new rules state that for children born called the change ‘particularly pernicious’, NHS and the wider economy ‘billions’, after 6 April into families where there are adding that children ‘should not have their warns new research. already at least two children will no longer life chances damaged because of the number A systematic review, published in the be counted in tax credit or universal credit of siblings they have’. Journal of Epidemiology & Community payments to their parents. A spokeswoman for the Department for Health, states that every £1 spent on From autumn 2018, families making new Work and Pensions said that ‘work is the public health returns an extra £14 on universal credit claims will only be eligible for best route out of poverty’ and that welfare the original investment. payment for their fi rst two children – even if reforms ‘are designed to support people The researchers found 52 studies they were born before this date – although into employment’. published over four decades that calculated a return on investment (ROI) for local and national public health initiatives or worked out the overall value for money of a project or proposal. The studies looked at 29 public health interventions in the UK, western Europe, the US, Canada, Japan, Australia and New Zealand. Critical analysis showed the average ROI for public health initiatives was 14.3 for every unit cost spent on it. The researchers said the fi ndings ‘clearly demonstrate that public health interventions are cost-saving, both to health services as well as the wider economy’. ● To read the study, go to bit.ly/JECH_public_health

6 Community Practitioner May 2017

6- s ound-u.indd 6 27/04/2017 13:20 NEWS ROUND-UP

COUNTRY NEWS WALES Meeting members Three meetings held in March aff orded Unite-CPHVA professional offi cers and executive committee members the opportunity to meet members across Wales. Taking place in Cardiff , Llanelli and Wrexham, the meetings took a Question Time-style format and invited members to put questions to a panel on the delivery of the Healthy Child Wales programme, which has now been in place for six months. The panel members were varied but included Assembly members, Welsh Government representatives, managers from both Flying Start and general services, and practice teachers. Term-time holidays on Topics of discussion included the importance of data collection and the up in England three- and six-month antenatal contacts. School nurses also Family holidays during term absences have continued to rise. debated the practicalities of skill time accounted for a quarter of The Department for Education insisted mix, safeguarding issues and school unauthorised school absences in that overall absence was at ‘historic lows’. handover issues. England, new data shows. A spokeswoman said that children More than 800,000 children missed at should not be taken out of school ‘without least one day of school in 2015-16, despite good reason’ and that every extra day of the threat of fi nes, compared with just school missed‘ has a lasting eff ect on their under 700,000 in the previous year. life chances’. Children in Yorkshire and the Humber ‘We are supporting schools and local and the north-east of England lost the most authorities to use their powers to tackle time to holiday, with an equivalent of 1.5 unauthorised absence,’ she added. school ‘sessions’ missed by every pupil. A session is defi ned as a morning or Conference in Cardiff afternoon at school. Bournemouth, Poole, Cornwall and KEY STATISTICS As the Unite-CPHVA annual conference Devon are among the areas with the gears up for Cardiff in October, highest percentage rise in holiday absences, members in Wales were encouraged while in Warrington and East Riding, family 801,980 to submit abstracts to showcase the holidays made up almost half of all missed good practice taking place. school sessions. children missed one or Further meetings to discuss If a school deems an absence to be more sessions of school for conference will be held later in the family holidays in 2015-16 unauthorised, the council can fi ne parents year by Wales regional executive £60 per child, which rises to £120 if it is not committee chair Michelle Moseley, paid within 21 days. and those interested in becoming a But teachers have blamed the high 691,910 local area representative can contact price of holidays and said fi nes were a regional offi cer Richard Munn at in 2014-15 (Source: Department for Education) ‘blunt instrument’ as unauthorised holiday [email protected] ALAMY/ISTOCK

May 2017 Community Practitioner 7

6- s ound-u.indd 7 27/04/2017 12:4 NEWS ROUND-UP

Practice closures ‘leave 200,000 without GPs’

Record numbers of GP practice for an extra £16m towards a closures have forced around ‘practice resilience programme’ 265,000 to move, according to this year, the profession feels its data published in April. funding needs are not being met. The fi ndings of a freedom Professor Helen Stokes- of information request made Lampard, chair of the Royal by Pulse magazine revealed College of General Practitioners, 57 practices closed in 2016, with said closing a practice was always a further 34 closing as a result ‘a last resort’ and that available of mergers. funding needed to be more The data also showed the accessible to practices. number of patients forced to NHS England argued that change surgeries increased by the fi gures obtained byPulse 150% from 2014, and by 15% were not accurate and included from 2015. patients whose details had Areas that have been been transferred after practices particularly aff ected include had merged. Brighton, which saw seven But shadow health secretary practices close in the past two Jon Ashworth said ‘urgent action’ years, according to Pulse. was needed to address the spike Despite NHS England’s pledge in practice closures.

COUNTRY NEWS SCOTLAND

including new content areas, such as off ers for practitioners include useful Health and minor ailment services and deep vein links, guidelines and reports, patient homelessness thrombosis, enhanced messages around information leafl ets, and education and New information on homelessness has maternity leave, safe sleeping and other training courses. been published online by the Scottish areas, and the improved design of ● For more details, go to Public Health Observatory (ScotPHO). existing content. cyans.org.uk The new section on the ScotPHO Any remaining 2016 print editions website includes an overview of the policy should be returned to the NHS board Inequality briefi ng on homelessness in Scotland, as well as for recycling. NHS Health Scotland has published its guides to data on the demographics and ● The guidance can be downloaded at eighth inequality briefi ng, which explores health of homeless people. It also reviews bit.ly/HS_RSB and bit.ly/HS_RST the role of income, wealth and poverty the relevant data sources and includes a in creating health inequalities, and the list of key resources and reports. Allergy support evidence for eff ective actions to reduce ● To see the information, go to Practitioners providing allergy care and health inequalities in this area. bit.ly/Scot_PHO_homeless advice to families are reminded to call As part of its ongoing work to inform upon the Children and Young People’s and develop future briefi ngs, Health Updated resources Allergy Network Scotland (CYANS), a Scotland is seeking your feedback in the NHS Health Scotland has published new resource to support both healthcare form of a short survey. editions of Ready Steady Baby and Ready professionals and ● To view the new briefi ng, go to Steady Toddler. the public in dealing healthscotland.scot The 2017 reprints, now available to with allergies. Complete the survey at order via local NHS health board resource The tools bit.ly/HS_briefi ng_ and information centres, contain changes that CYANS survey

8 Community Practitioner May 2017

6- s ound-u.indd 27/04/2017 14:7 NEWS ROUND-UP

Sexual health services harder to access in the UK, study fi nds

It has become more diffi cult to access sexual health services in the UK, new research has suggested. A study of 220 of the UK’s 248 genito- urinary medicine (GUM) clinics revealed in many areas access has fallen below the recommended standards that 98% of patients should be seen to within 48 hours of contacting the service. But in 2015, fewer than 91% of researchers posing as patients with symptoms could get appointments within this period. And the researchers purporting to have no symptoms were only granted Poll finds mental health appointments within 48 hours in less than 75% of cases. While GUM clinics in Wales and issues starting from four Northern Ireland off ered the lowest overall access, the sharpest decline Children as young as four are suff ering The impact of these problems was has occurred in England. from panic attacks, anxiety and seen in a pupil’s inability to concentrate, Lead author Elizabeth Foley of the Royal depression, a poll has found. participate fully and make friends. South Hants Hospital expressed concern A poll of 2051 teaching staff found 98% NASUWT general secretary Chris Keates that ‘patients will go undiagnosed and pass of them had come into contact with pupils said teachers were concerned about the their infection on to other people’. experiencing mental health issues. diffi culties faced in getting help for children She said the situation has deteriorated Of those polled – all members of the with mental health needs, adding that since 2010, when the 98% target set by the teachers’ union NASUWT – 91% said they cuts to budgets and services in local British Association of Sexual Health and were aware of pupils suff ering from panic authorities had ‘taken a heavy toll on the HIV (BASHH) stopped being mandatory. attacks, 79% suspected depression and 64% support available’. Another factor she cited is the transfer of knew a student who was self-harming. Among the reasons cited for the increase GUM clinic funding from the NHS to local While most of the children in question in mental health problems among children authorities, adding that a quarter of all were teenagers – with 58% of teachers and teenagers were family problems such clinics are reporting a 20% drop in funding. saying they had seen issues in 15 to as ill health or break-ups (according to 91% Elizabeth Carlin, president of BASHH, 16-year-olds – almost a fi fth (18%) said they of teachers), the pressure of exams (84%), said the research provides strong support had been in contact with four- to seven- social media (72%), the pressure to do well for the reintroduction of ‘a mandatory 48- year-olds showing mental health issues. academically (71%) and bullying (36%). hour access target’. ●The study can be found at bit.ly/STI_foley_GUM KEY FINDINGS

98% 91% 79%

of teaching staff come into said they were aware suspected contact with pupils with of pupils suff ering depression in pupils mental health issues panic attacks they worked with ISTOCK

May 2017 Community Practitioner 9

6- s ound-u.indd 27/04/2017 12:4 RESEARCH NEWS

US UK Smoking ‘kills one in 10’ worldwide Love it or hate it… One in 10 deaths around the world in 2015 was caused by A spoonful of Marmite a day may regulates the balance needed smoking, and just over half of them occurred in China, India, stimulate the production of a for a healthy brain. GABA the US and Russia. chemical associated with healthy imbalances are associated with a These were the key fi ndings from an analysis of the Global brain function, say researchers at variety of neurological disorders. Burden of Disease Study 2015, published in The Lancet. the University of York. Lead author Anika Smith, PhD Led by Dr Emmanuela Gakidou at the University of EEG recordings showed that, student at York’s Department of Washington in Seattle, the analysis also found that around compared with a control group Psychology, said: ‘These results one in four men and one in 20 women smoked every day, which ate peanut butter, people suggest that dietary choices making almost one billion globally. who consumed Marmite every can aff ect the cortical processes The researchers suggest that population growth and day for a month had a reduction of excitation and inhibition tobacco fi rms targeting developing countries are the main of around 30% in their brain’s that are vital in maintaining a reasons for the high numbers. ‘Despite more than 50 years of response to visual stimuli. healthy brain. anti-tobacco eff orts, smoking remains a leading global risk Researchers think the vitamin ‘This is a great starting point factor,’ the report said. B12 in Marmite explains an for exploring whether a more ‘Its toll will remain substantial increase in the levels of refi ned version of without more concerted the neurotransmitter this technique could policy initiatives, policy GABA, which inhibits have some medical compliance and enforcement, the excitability of or therapeutic and sustained political will to neurons in the brain. applications in off set commercial interests.’ This chemical the future.’ ●To fi nd out more, go to ‘turns down the ●The research can bit.ly/Lancet_GBDS_review volume’ of neural be viewed at bit.ly/ responses and JoP_smith_marmite

UK UK babies ‘cry more’ than in other industrialised countries Babies in the UK cry more than in to two weeks), Canada (34.1% a number of other industrialised at three to four weeks) and Italy countries, new research suggests. (20.9% at eight to nine weeks). A study published in The Researchers said reasons Journal of Pediatrics found the for the diff erences between highest levels of colic were countries could include levels also in Canada and Italy, with of social inequality, maternal the fewest crying babies in soothing techniques and Denmark, Germany and Japan. feeding patterns. The research, which attempted Lead researcher Professor to create a universal crying Dieter Wolke from the University chart, involved analysing 28 of Warwick said that babies previous studies that looked at ‘are already very diff erent in the prevalence of colic in the fi rst how much they cry in the fi rst three months across more than weeks of life’ and that the 8500 infants. research could ‘help healthcare The highest levels of colic, professionals to reassure parents quantifi ed as crying for more whether a baby is crying in the than three hours a day for at least normal expected range’. three days a week, were found ●To view the study, go to in the UK (28% of infants at one bit.ly/JoP_wolke_colic

10 Community Practitioner May 2017

10-11 sa s.indd 10 27/04/2017 12:0 RESEARCH NEWS

US Vitamin D defi ciency link to heart disease risk

US Vitamin D defi ciency in overweight children and adolescents may be an early sign of Omega-3 benefits could ‘depend cardiovascular disease, says a new study. Researchers looked at the medical records, on children’s weight’ which included vitamin D levels, of 178 young people aged six to 17 who attended Body weight may be pivotal in deciding in foods such as salmon and walnuts. the paediatric endocrinology outpatient how much benefi t children get from Lead author Lisa Christian at Ohio clinics at Weill Cornell Medicine in New York eating ‘good’ omega-3 fats, says State University said that parents over a two-year period. new research. looking to feed their children more Lead author Marisa Censani said the The researchers compared fatty acid of these foods should be mindful that as fi ndings suggested vitamin D defi ciency uptake to overall body weight and the children gain weight they will need may cause ‘an increase in cardiovascular risk body mass index after children took an more of them to make a diff erence. among children and adolescents’. omega-3 supplement, and found that ‘While this study just looked at fatty ●Read more at the more a child weighed, the smaller the acid supplements, it’s important to bit.ly/endocrine_censani_vitd measurement was of two key fatty acids in recognise that weight diff erences could their bloodstream. factor into how children and adults Omega-3 fats have been shown to respond to many types of medications,’ lower blood pressure and increase good she added. ITALY cholesterol (HDL) in children aged eight ●Read the study at to 15. The fatty acids are found naturally bit.ly/PO_christian_omega Mothers’ voices matter,, says study

Simply hearing their GERMANY mothers’ voices can boostst Pool toy smell could signal hazardous substances the health of premature babies, suggests a revieww Rubber rings, armbands and other infl atable and bathing rings bought in Germany, of published research. toys could contain a range of potentially all of which were found to be made from The review, published hazardous substances – as indicated by their polyvinyl chloride. in Acta Paediatrica, lookedd distinctive smell – a study has found. Up to 46 odours were detected in each at 15 studies covering 5122 Some of the chemicals, which include sample, 13 of which were ‘intense’. Volunteers preterm infants between carbonyl compounds, cyclohexanone, smelled each product, with one prompting 2000 and 2015. phenol and isophorone, could be critical comparison with glue and nail polish. It found that hearing the maternal voice when present in higher concentrations Lead author of the report Christoph was linked to more stable biological and in children’s toys, say the researchers of a Wiedmer said: ‘In a number of cases our behavioural function among the infants, study published in Analytical and noses can guide us to “sniff out” and fewer heart and lung problems. Bioanalytical Chemistry. problematic products.’ Lead author Dr Manuela Filippa called The team conducted ●View the research for caring teams to support vocal contact. tests using a beach at bit.ly/ABC_ ●Read the research at

ALAMY/SHUTTERSTOCK/ISTOCK ball, armbands wiedmer_smell bit.ly/AP_fi lippa_voice

May 2017 Community Practitioner 11

10-11 sa s.indd 11 27/04/2017 12:0 THE BIG STORY LIN GG G A JU C T A

Public health nursing in England is undergoing For example, Nottinghamshire County Council’s three-year contract for a new 0 to massive changes, with school nursing and health 19 service, awarded to the Nottinghamshire visiting being blended into integrated 0 to 19 Healthcare NHS Foundation Trust, entails annual savings of up to £2.3m, as the services. Community Practitioner asks what this budget shrinks from £15.3m in 2016-17 to £13m by 2019-20. means for the services, the practitioners and the Here the new service brings together communities they serve. under one contract health visiting, school nursing, family nurse partnership, the national child measurement programme any community nurses in service, which removes the prior distinction and breastfeeding support services. England have experienced between provisions for 0 to fi ves and Formed of 20 new locally based ‘Healthy turbulent times since those for school-age children. It also often Family Teams’, the new workforce commissioning responsibility subsumes – or even removes – family nursing comprises more support staff and fewer for school nursing services partnership teams too. health visiting posts. Mtransferred to local authorities in April 2013, These changes are being pushed followed by services for birth to fi ve-year- through as councils receive £84m less JOB LOSSES olds in October 2015. from the government for public health Inevitably, as elsewhere, changes have As public health budgets are slashed in 2017-18, which follows a £77m reduction meant job losses. The council originally and local authorities face unprecedented the year before, and a £200m cut in intended to axe 38 whole-time equivalent fi nancial constraints, this major shift has 2015-16, according to Local Government posts from a workforce of around 138 already seen job losses, down-banding, Association fi gures. – aff ecting 60 staff . But following an altered skills mixes in teams and even some With local authorities under crushing intervention by Unite, the number of services axed altogether. fi nancial constraints, money saving is a posts at risk was reduced to 19. What appears to be emerging is a blended fundamental requirement of any new service. Other councils have been more radical

12 Community Practitioner May 2017

12-13 Big Story v2.indd 12 27/04/2017 14:58 THE BIG STORY

still. Cumbria County Council has axed absolute tragedy’, according to Terry Cunliff e, traditional school nurses altogether, the Unite regional lead offi cer for health in claiming the £927,000 a year service is THE STORY IN NUMBERS the North East, Yorkshire and Humberside. now unaff ordable. Here the council put out to tender public It is also cutting the number of health health services for under-19s with a tender visitors. Those remaining will now manage £1m less than the prior running costs. South caseloads at the limit of national guidelines and West Yorkshire Partnership NHS Trust – around 300 babies and children each. £14 refused to take it on – so the council has Cumbria is also scrapping the family The average amount that will be taken the service – and the staff delivering nurse partnership scheme and redeploying returned to the wider health and it – ‘in-house’. some of the specialist health visitors to a social care economy for every £1 Here, says Terry, a ‘signifi cant proportion’ invested in public health according new ‘strengthening families’ team, which to the Journal of Epidemiology & of skilled nurses have chosen to ‘vote with will handle a smaller caseload comprising Community Health. their feet’ rather than transfer to Barnsley the most complex cases and the area’s most County Council. vulnerable families. Those who remained lost their NHS terms and conditions and NHS pensions, he adds, WATERED DOWN and some faced down-banding. Elsewhere, school nurses have seen their He maintains that such cuts to funding roles change and elements of their remit £361m and staff can only lead to a poorer service, sliced away. The reduction in the amount local despite the council’s assurances otherwise. Claire Elwell, school nursing member of authorities receive from government ‘We believe we will see an increase in child the CPHVA executive committee, says school for public health since 2015-16. safeguarding issues, an increase in teenage nurses’ role in safeguarding – a key part of pregnancies,’ he says. their jobs until now – had been ‘watered down’ in Sunderland. MASS EXODUS She adds: ‘We are asked to give them a He says in York, skilled community nurses health assessment and, if there are no health 899 have been leaving in droves over the city needs, we are encouraged to withdraw as The fall in the number of health council’s plans, which include cutting their visitors in the NHS in England in soon as possible – with no time for a holistic one year following the transition number by around 16% and changing work assessment. But the child still sits within of commissioning responsibility to and pension conditions for those remaining. our caseload, although we’re not actually local authorities. Terry adds that one of the proposals in involved with it, and that’s very hard.’ York is for school nurses to retrain as health While the new 0 to 19 service is ‘still in its visitors – but he said he has seen no plan infancy’ adds Claire, she fears that ultimately to fund or provide staff working time to skills may be lost. ‘There are similarities and 164 undertake the necessary study. key skills across school nurses and health ‘Health visitors are trained to degree level,’ The fall in the number of school visitors; however, their caseload sizes are nurses working in the NHS in he adds. ‘The transfer of these skills is not vastly diff erent, as are their priorities and England between October 2015 going to be undertaken in any meaningful client bases. I worry we are going to lose a lot and October 2016. way at a night or a weekend school.’ of experience, a lot of specialisms. While the picture is mixed at a local level, ‘Management are looking at a bigger skill nationally numbers of health visitors and mix and bringing staff nurses back in to do school nurses are falling. some of what the Band 6 nurses do – they £2.3m Unite lead professional offi cer Obi Amadi want more for less.’ says: ‘Families with young children and Annual savings required of Claire says: ‘Since the transition to local Nottinghamshire Healthcare NHS babies are facing a ticking health time- authority commissioning, Sunderland has Foundation Trust’s 0 to 19 service bomb because of the sorry and sad decline gone from 16 Band 6 school nurses to eight. up to 2019-20. in health visitor and school nurse numbers They replaced the Band 6s with Band 5s, but – this can’t be right for a strong preventative the Band 6s remain accountable of the public health policy.’ wider picture.‘ These new ways of working are still in She adds: ‘I don’t want to be a dinosaur their earliest stages – as ever in public and say things shouldn’t change, but it £84m health, the impact will not be seen for years doesn’t feel very good on the front line at The reduction in government public to come. The fear is, if poor choices are the moment.’ health funding to English councils in made now, ultimately the public will pay

ISTOCK In Barnsley, the transition has been ‘an 2017-18. the price. CP

May 2017 Community Practitioner 13

12-13 Big Story v2.indd 13 27/04/2017 14:58 RIGHTS AT WORK

Sarah Carpenter, Unite Pay: what’s head of health, explains how the Pay Review Body’s report is at odds with the government’s going on? 1% NHS pay rise.

very year, for the last 30 years, pay sector pay policy, and unions were extremely Interestingly, it was not just the PRB rises in the NHS have been based vocal about this derisory sum. But drill that came to this conclusion. The House of on recommendations made by the down below the surface and there are some Lords select committee on the long-term NHS Pay Review Body (PRB). The interesting points made by the PRB: sustainability of the NHS delivered its report PRB is made up of seven people, ● The report is critical of the government’s in early April, and criticised ‘shortcomings usually E with a business background and pay policy. It says: ‘We are concerned in workforce planning’, ‘poor’ workforce independent of government, who hear that in too many places the default strategy and the ‘indisputable link between evidence from all interested parties, analyse strategy [is to expect] NHS staff to work a prolonged period of pay restraint on one that evidence and reach a conclusion. more intensively, in more stressful hand and low levels of morale and workforce This is then published in a report, and the environments, for pay that continues to retention on the other’. politicians in England, Wales, Scotland and decrease in real terms. We do not consider Northern Ireland decide whether to accept this a sustainable position.’ WHAT DOES THIS MEAN? the recommendations. ● Staff are also bearing the brunt of the cuts ● The pay rise of 1% will be backdated to In 2014, health secretary Jeremy Hunt agenda in the NHS. The report says: ‘We 1 April and is being paid to all pay bands caused anger when he failed to accept are concerned that holding down pay has and pay points in England, Wales and the recommendations, and industrial become the default position for making Scotland. In addition, 1% will be applied to action followed. Indeed, slightly diff erent effi ciencies, as service transformation the minimum and maximum of the high approaches across the four countries have is not yet delivering. Reliance on pay cost area supplement created four diff erent pay scales, which this to meet the aff ordability challenges ● Given the political situation in Northern year’s report has concluded are ‘an inevitable risks putting further pressure on the Ireland, there has been no decision yet feature of devolved health policy’. real wages of NHS staff and creating a about whether the recommendations This year’s PRB report was once again perception of unfairness which could be have been accepted shackled by the government’s 1% public counterproductive due to its impact on ● In Wales, Scotland and Northern Ireland recruitment, retention and motivation.’ work will be done to look at the impact of ● The report also raises the impending the government living wage. impact of Brexit and bursary removal on staff supply, urging governments WHAT’S NEXT? to consider a more strategic We’ll be asking members across the health approach to these issues – sector for their thoughts on pay, and including a people strategy, what the next moves might need to be incentivising agency staff in addressing the government’s policy to to join the NHS or making cap public sector pay, which has led to the targeted pay awards on an real-terms decrease in pay for NHS staff occupational/geographical of around 17% since 2010, and the lack of basis over the 1% available independence for the PRB. One thing is for for the general pay award. certain, though – we will all have to continue While Unite has concerns to stand up and speak out. CP about some of the suggestions, the idea of geographical pay fi ts ● To read the PRB report, go to bit.ly/ in too neatly with the sustainability NHS_PRB_2017; for more on the Five year and transformation plans (soon to forward view update, visit bit.ly/NHSE_ become partnerships) and there FYFV_review; and to see the House of is a clear message: pay restraint Lords committee report on sustainability,

isn’t working. go to bit.ly/Lords_NHS_sustainability ISTOCK

14 Community Practitioner May 2017

14 Rights at Work.indd 14 27/04/2017 12:52 FEEDBACK Your views Music has a powerful infl uence and, as one health visitor has discovered, can act as a calming and memory-prompting tool for dementia patients, and possibly help others too.

Many yearsears ago, I worked as a nurse aandnd we ooftenften have a phphysicalysical response in on a long-stayg-stay ward forfor the elderly.elderly. It tapping our ffeeteet and dancing.dancing. was commonmmon practicepractice at the time for I can see tthishis initiative playingplaying a rolerole the radioo to bbee pplayinglaying in tthehe ddayay room in manymany other areas of nursing, such as where thehe residents sat. I recall one ladylady ppalliativealliative care and supportinsupportingg those with singing along,along, word perfect,perfect, to a hit songsong learnilearningng didiffiffi culties. MyMy own daughter,daughter, by Julio IgIglesias.lesias. Even more surprising wwhoho is on tthehe autistic sspectrum,pectrum, was thatt thisthis ladylady diddid not usuallyusually havehave loves listening to music that reflrefl ects words too exexpresspress herselherselff and here she how she is ffeeling.eeling. And a mother was, smilingiling and tappingtapping her fi ngersngers to exexperiencingperiencing ppostnatalostnatal depressiondepression the music.sic. could perhaps use personalised As a hhealthealth visitorvisitor I’m aawareware of the mmusicusic as a copingcoping strategstrategy.y. power of sensorsensoryy experiences – such as If this approachapproach can promotepromote a when babiesabies recognise ttheirheir mothersmothers by dedeepereper understandiunderstandingng ofof our clientsclients the scentnt ooff bbreastmilkreastmilk andand turnturn toto theitheirr aandnd facilitate greatergreater person-person- mother’s’s voice shortlyshortly afterafter birth. For this centrecentredd care, suresurelyly it’s wortworthh reason I decideddecided toto becomebecome a trtrainerainer with lookinlookingg into.into. CP Playlist forfor Life.Life. The charityharity was startedstarted by SaSallylly SurrinderSurrinder Sandham-Sandham- Magnussonsson (dau(daughterghter of TV presenterpresenter BainsBains,, healthhealth Magnus)s) ffollowingollowing the death ofof her vivisitorsitor mum in 2012.2012. MMamieamie hhadad ssuffuff eredered withwith vascularr dementia and the familyfamily foundfound no matterer how confused and aagitatedgitated she becameame at times, thetheyy could stillstill reach herer throthroughugh the music that had been partart ooff her lifelife beforebefore she became ill. Even whenwhen sheshe couldcould no longerlonger hold a conversation,onversation, Mamie coucouldld stistillll rememberber the wordswords aandnd melodies.melodies. Our abilitybility to respond to music is one thingng dementia cannot destroydestroy becausee it stimstimulatesulates mmoreore neneuralural connectionstions tthanhan anyany otherother human iinterventionntervention in ddementiaementia care. Wee know that listenilisteningng to musicc enengagesgages multiple parts of the brain – we have an emotionaltional reactionreaction stimulatedted bbyy memoriesmemories,, ISTOCK

MayMMaayay 220201701177 ComCoCCommunityomommunmmuunityiittyty PrPPractitionerracactactctititiititioneononen r 1515

1 da.indd 1 27/04/2017 12:2 ONE-TO-ONE

You have to

As her constituency hen Community joins the many areas are not to be overlooked, Rachael observes. Practitioner catches up Because it is envisaged that health visitors with Rachael Maskell, of England facing will lead the new team, she says, school it’s just days after a substantial cuts to nurses ‘could see the downgrading of their protest took place money’ as they’re moved onto the local inW her constituency. Health visitors and public health services, authority terms and conditions. ‘So we’ve got school nurses gathered at the Unite-led Rachael Maskell MP the pay issue, the reorganisation issue and demonstration to alert the 200,000 people clearly an issue of safeguarding services all covered by City of York Council about shows no signs of giving being rolled into one,’ she adds. proposed cuts to these services. As MP for York Central, Rachael is at the helm of up the fi ght. The former PATTERN OF CUTS ongoing talks with the council, and as Unite’s Unite head of health Of course, the scenario in York is by no former head of health she understands just means exclusive and Rachael acknowledges what is at stake. explains to Helen Bird that services up and down England are being ‘We’ve already seen the ending of certain why the profession has placed in the same vulnerable position. ‘I services: we saw the end of smoking think local authorities are slashing services cessation and health checks brought in by a duty to follow suit. at the moment left, right and centre because the local authority, and now we’re moving even with the £2bn from the government into looking at early years,’ she says. Rachael explains that she’s worked hard to social care – which I think is shockingly ‘So in trying to reorganise the service, the to highlight how important it is to ensure poor and which we need this year and not in suggested way forward is to have a blend of children have a strong foundation and three years – local authorities are climbing health visiting and school nursing, with non- ‘that we don’t see the depletion of health the walls about how they’re going to provide specialist community public health nursing visiting and school nursing’. And while York safe services for children, for vulnerable (SCPHN) staff providing support. council’s director of public health, Sharon people, for older people,’ she says. ‘There are only three SCPHN-trained Stoltz, has a background in health visiting Indeed, it is for the preservation of these school nurses, I was told, covering the city and ‘understands the importance of that’, vital services that Rachael has spoken out, now, so we’re already seriously depleted she is nonetheless constrained by the need she tells us: ‘I’ve been vocal on two parts: in the support we need in our schools. to make budget cuts, Rachael adds. The one, that we absolutely have to protect the I’ve talked frequently with the education proposed solution is to train health visitors early years service and school services, but service – they’re battling with all sorts of in school nursing and school nurses in health also really highlighting that you cannot cut issues around wellbeing in the classroom, visiting, in order to equip each practitioner to public health services because there are mental health – and we need to make sure off er a full 0 to 19 service. serious consequences.’ children are getting a full service.’ But the issues with reorganising in this way Part of the solution, she believes, is to have

16 Community Practitioner May 2017

16-17 n to n.indd 16 27/04/2017 14: ONE-TO-ONE

ALL ABOUT RACHAEL

● Has a degree in physiotherapy from the University of East Anglia and worked for the NHS as a care worker and physiotherapist for 20 years ● After serving as Unite head of health, was elected Labour MP for York Central in 2015 ● Resigned as shadow environment, food and rural aff airs secretary after just eight months in the role as part of the Labour party’s post- Brexit reshuffl e ● Is a keen tweeter and can be found @RachaelMaskell ● Is a keen cyclist and rode from parliament to the 2015 Labour conference in Brighton for the British Heart Foundation.

‘I think the budget has to be ring-fenced – I think it’s the only way,’ says Rachael. ‘We know all the problems – people are starting to call potholes in roads “public health”, so I think we have to ring-fence the budget.’ Rachael uses the example of sexual health services. ‘I think all of that money a more joined-up approach. ‘I’ve been quite to take councillors out and about with the needs protection,’ she says. ‘Is [sex and critical of the segregation between the NHS school nursing and health visiting services relationships education] going to be taught and public health,’ she says, ‘because while so they actually understand the immense by practitioners, like school nurses, who can I understand wider ways of addressing the value that these professionals bring to really advise or is it going to be something social determinants of public health are their communities. else that teachers, ill-equipped to teach this going to be through better housing, better ‘That education is needed for local stuff , are going to have to teach? education and so on, the problem is that politicians,’ she adds. ‘School nurses really should be making the public health doesn’t see the return. Perhaps the association they’re failing to case to use their professional skills,’ she adds. ‘It’s the NHS that sees the return on the make is the vital role public health nurses Of course, this is really the take-home investment, and the return is a long way play in reducing poor health outcomes due message for practitioners, Rachael believes: away,’ she adds. ‘Because of short-term to societal inequalities – a very real problem to speak up and be heard. thinking, [local authorities] are saying: “We’ll across the UK that will only worsen the more ‘You have to bite,’ she says. ‘We know that make the cuts now – that doesn’t politically cutbacks are made. ‘This is what 1001 critical practitioners were told [by York City Council] hurt us on our watch.”’ days is all about: ensuring that everybody that it was disappointing they were taking has access to equal services and support to such action in protesting, but the thing SHOW AND TELL create a more equitable society in the future,’ is, if you don’t fi ght you may well lose But as Rachael notes, a lack of understanding she adds. those services. among politicians around ‘what health ‘And I believe it’s your professional visitors and school nurses actually do’, DUTY OF CARE responsibility to stand up for the work contributes to the apparent lack of urgency In the meantime, what practitioners are that you do, and if you believe in public to save these services. currently being forced to accept is that local health then part of that duty you have is ‘I think that goes across the country,’ she authorities and commissioners are also to ensure those services remain in your says, suggesting that more initiatives, such under pressure from central government to location and therefore you have to – as the ‘day in our shoes’ event held by Unite make substantial savings. Where else should diffi cult though it may be – really stand in Wales, could be helpful. ‘Maybe we need they be made from if not public health? up for the next generation.’ CP

May 2017 Community Practitioner 17

16-17 n to n.indd 17 27/04/2017 14: LOBBY EVENT

Lobbying against the

With health visitor and school nurse numbers falling, Unite-CPHVA held an event at parliament as part of a drive to protect the professions.

ver 100 health visitors and seen fi rst-hand the impact that you have and school nurses crowded into a want to give you my support,’ he said. committee room at parliament The event was held to highlight the fact at the end April for an event to that since the commissioning of children’s lobby MPs. The briefi ng was a public health services moved from the NHS Ochance to rally against the biting cuts to the to local authorities in 2015, the number profession and discuss how members can of health visitors and school nurses has engage politicians and the public and unite nosedived. In a single year health visitor them behind the cause. numbers fell by nearly 9%, while the already Members came from all over the UK to low numbers of qualifi ed school nurses fell attend the session and many invited their by 6% – to just 2561 posts – last year. MPs in order to discuss the issues facing Unite-CPHVA offi cers speaking at the health visitors. A handful of politicians event encouraged members, including did attend, from areas including South community nursery nurses who are facing WORKING WITH YOUR MP Derbyshire, West Yorkshire, Staff ordshire the same issues, to contact their MPs. and North London, among others (see box Obi Amadi, Unite lead professional ● Invite them to come and visit you for tips on how to ask your MP to help). offi cer, said: ‘What we are doing isn’t to observe you working in practice Shadow health secretary for England, Jon about protecting jobs; this isn’t about the so that they can see fi rst-hand what Ashworth, spoke at the meeting just hours workforce; this is about reducing risk and you do after revealing a number of key pledges if improving health. a Labour government were to be elected. ● Request that they pass on your These include scrapping the NHS pay cap, concerns to the secretary of state reintroducing student bursaries and having for health safe staffi ng levels for the NHS introduced We need them to stop into legislation for the fi rst time. All of these cutting and to start ● Ask for a moratorium on were welcomed with applause by those further cuts and a review of the assembled in the room. thinking about the commissioning process until After outlining the proposals, he went on long-term implications agreements are reached with local to praise the profession. ‘In me, as a shadow authorities, NHS employers and health secretary (and hopefully a health of what they are doing trade unions. secretary), you have a friend, an ally. I have to the nation

18 Community Practitioner May 2017

1-1 o nt3.indd 1 27/04/2017 13:43 LOBBY EVENT

‘Any members that haven’t done updates. A ‘Love your health visitor, save ssoo need to write to their MPs and talk our services’ petition set up by members ttoo local parents groups about how has almost reached its target of 10,000 imimportant our role is. It’s also a good signatures (see box). In addition, proposed ididea to talk to colleagues in the cuts around the country have been scaled NHSN about what happens if we are back, including plans to scrap all school notn there, because the role that we nurses in York, diluted to a reduction of providep is massive.’ just 5%. Jenny Harmer, a health visitor Sarah Carpenter, Unite head of health, fromf Merton, was also at the event. said: ‘We need to stop the cuts and to start ‘All‘A the squeezes, cuts and changes thinking about the long-term implications of tot health visiting are having an what is being done to the nation.’ effe ect on the families that we She added that members should focus are looking after and I’m really on four vital actions: writing to those in concerned,’ she said. positions of power; talking to colleagues and ‘I have written to my MP, Harriet friends; ensuring they are organised; and Harman, and today has given me maintaining the campaign momentum. CP some ammunition as to how to ● There are a number of resources and a ‘If you have a chance to speak to and lobby raise these issues further.’ range of information on engaging with MPs, then tell them about what you do and Among the calls for members to fi ght politicians and the local community at ask them to debate these issues.’ for the profession, there were also positive unitetheunion.org/health Health visitor from Staff ordshire Su Lowe is a member who has been trying to engage LOVE YOUR HEALTH VISITOR her MP, Margot James, and has also been trying to speak to Nicola Blackwood – the At the time of going to press, the ‘Your health visitor, save our services’ online MP who is responsible for public health. petition was just a few hundred signatures short of its 10,000 target. ‘I think the most important thing about On 26 April, the petition had been signed by 9280 people. this campaign is to let people know about This petition calls on the government to provide additional, ringfenced the service and the role that we provide,’ funding to local authorities to improve the commissioning of health visiting she said. ‘The good news is that when we services in England. start to tell people about what we do, they It says: ‘As health visiting services come under the care of local councils, really listen and realise how important it is.’ councils have had their public health budgets cut and many are unable to commit She continued: ‘Someone has to take to commissioning health visiting going forwards without cuts to their services, charge of this and if not MPs, then who else? down-banding and redundancies of health visitors.’ It is their job to represent us and to represent ● For more information and to sign the petition, visit bit.ly/LYHV_petition the children that we care for.’

May 2017 Community Practitioner 19

1-1 o nt3.indd 1 27/04/2017 13:43 INFORMATION FOR HEALTHCARE PROFESSIONAL USE ONLY ADVERTORIAL FEATURE BREASTFEEDING IS BEST FOR BABIES Infant refl ux and regurgitation – how should it be managed successfully?

Infant regurgitation Starch thickener helps to NEW SMA® PRO Anti-Reflux is specifi cally is a common functional reduce frequency and volume designed for the dietary management of gastrointestinal disorder of regurgitation in infants7,8 refl ux and regurgitation. It is nutritionally 1 complete and suitable from birth. in an infant’s fi rst year Starch is an appropriate thickener for Gastro-oesophageal refl ux (GOR) is a infants with refl ux and regurgitation Unique combination of easily normal physiological process in otherwise as it can be digested by the infant. digestible starch and 100% whey, healthy infants. It is the involuntary passage Starch thickened formulas have proven partially hydrolysed protein of gastric contents from the stomach into effi cacy in reducing the number of 7,8 the oesophagus, and when the refl ux daily regurgitation episodes as well as Lowest protein Anti-Refl ux 7 is high enough to be seen it is known as reducing the volume of regurgitation. formula* with 1.3 g of 13–16 2,3 protein/100 ml regurgitation. Regurgitation occurs daily Partially hydrolysed, 100% in about 50% of infants under 3 months New, easier preparation of age2 and is primarily due to functional whey protein accelerates immaturity of the stomach inlet.4 gastric emptying Symptoms peak at 4 months, usually 5 Although the mechanism of GOR is not For babies currently using resolve by 12–15 months and do not ® require further specialist assessment.2,6 fully understood, gastric emptying may SMA Staydown , this product play a role4. Whey dominant formulas, can be used in its place NICE recommend the containing partially hydrolysed protein following measures for accelerate gastric emptying time making the formula easy to digest (see graph managing formula-fed infants below).8,9 The UK Department of Health with frequent regurgitation also recognises that whey protein is easier with marked distress6: to digest.10 1. Off er parental reassurance Protein and the importance 2. Review feeding history, suggest smaller of slower growth rates more frequent feeds (while maintaining appropriate daily milk volume intakes) A lower protein content formula has shown to provide growth rates more 3. Trial of a thickened formula like a breastfed baby11. This slower growth 4. If this stepped-care approach is rate has shown to have signifi cant long- unsuccessful, stop the thickened term health benefi ts, including a lower Visit us for more information: formula and off er alginate therapy risk of obesity, cardiovascular disease smahcp.co.uk or smahcp.ie for a trial of 1–2 weeks. and diabetes.12 SMA Careline UK: 0800 0 81 81 80 Rate of gastric emptying after 120 minutes, according to the type of milk9 ROI: 1800 931 832 Type of milk 40

Breast milk 35 39%*

100% whey, partially hydrolysed formula 30 Intact whey-predominant formula 25 Intact casein-predominant formula 26% 20 15 18% Supporting you to support parents p<0.05 versus 100% whey, partially 16% * in stomach % remaining hydrolysed formula and breast milk 0 Type of milk References: 1. Van Tilburg MA, Hyman PE, Rouster A, et al. J Pediatr 2015; 166: 684–689. 2. Vandenplas Y, Rudolph CD, Di Lorenzo C, et al. J Pediatr Gastroenterol Nutr 2009; 49: 498– IMPORTANT NOTICE: The World Health Organisation (WHO) has recommended that pregnant 547. 3. Benninga M and Nurko S et al. Gastoenterology 2016; 150: 1443–1455. 4. Fonkalsrud EW. Curr Probl Surg 1996; 33(1): women and new mothers be informed on the benefi ts and superiority of breastfeeding – in 1–70. 5. Hegar et al. Acta Pediatr 2009; 98: 1189–1193. 6. NICE particular the fact that it provides the best nutrition and protection from illness for babies. Gastro-oesophageal refl ux disease: recognition, diagnosis and management in children and young people, 2015. Mothers should be given guidance on the preparation for, and maintenance of, lactation, with 7. Nestle data on fi le. 8. Indrio F et al. J Pediatr and Neonatal special emphasis on the importance of a well-balanced diet both during pregnancy and after Individualized Med 2015; 4 (2). 9. Billeaud C, Guillet J, Sandler B. Eur J Clin Nutr 1990; 44 (8): 577–583. 10. NHS delivery. Unnecessary introduction of partial bottle-feeding or other foods and drinks should Choices. Types of formula milk (2016). Available at http:// be discouraged since it will have a negative eff ect on breastfeeding. Similarly, mothers should be www.nhs.uk/Conditions/pregnancy-and-baby Pages/types- of-infant-formula.aspx. Accessed January 2017. 11. Alexander warned of the diffi culty of reversing a decision not to breastfeed. Before advising a mother to use et al., 2016. Growth of infants consuming whey-predominant an infant formula, she should be advised of the social and fi nancial implications of her decision: for term infant formulas with a protein content of 1.8 g/100 kcal: a multicenter pooled analysis of individual participant data. example, if a baby is exclusively bottle-fed, more than one can (400 g) per week will be needed, Am J Clin Nutr doi: 10.3945/ajcn.116.130633. 12. Singhal A & so the family circumstances and costs should be kept in mind. Mothers should be reminded that Lucas A. Lancet 2004; 363: 1642–1645. 13. SMA® PRO Anti- Refl ux data card. Available at www.smahcp.co.uk/content/ breast milk is not only the best, but also the most economical food for babies. This product must sma-nutrition-range/products/anti-refl ux. Accessed March be used under medical supervision. SMA PRO Anti-Refl ux is a special formula intended for the 2017. 14. Aptamil Anti-Refl ux and Cow & Gate Anti-Refl ux datacards. Available at www.eln.nutricia.co.uk/our-products. dietary management of bottle-fed babies when signifi cant refl ux (regurgitation) is a problem. Accessed March 2017. 15. Hipp Organic anti-refl ux datacard. It is suitable as the sole source of nutrition up to 6 months of age, and in conjunction with solid Available at www.hipp4hcps.co.uk. Accessed March 2017. 16. Enfamil AR datacard. Available at www.nutramigen. food up to 12 months of age. If the baby’s refl ux does not improve within 2 weeks of starting co.uk/hcp. Accessed March 2017. SMA PRO Anti-Refl ux, or if the baby fails to thrive, the family doctor should be consulted. *In the UK and Ireland

®Registered trademark SMA® Nutrition UK and Ireland NWHS003 ZTC1687a/03/17

p20.CPMAY2017.indd 20 26/04/2017 11:37 PERSONAL REFLECTION Learning from

’ve loved my career but the saying ‘life’s too short’ is all too real for me. So, after 39 years of working in the NHS, the time has experience come for me to leave. As retirement looms I’m thinking about new beginnings, but II’ve come to the end of a very long chapter. Anne Chitty is retiring after 32 years as The majority of my health visiting career has been based in inner city Leeds but a health visitor and has plenty to refl ect I’ve worked in rural west Wales, Sheffi eld and with the VSO in the Gambia. I’ve been on. She describes the changes and welcomed into the homes of thousands challenges that have defi ned her career. of families, I’ve shared people’s joy and tragedies, and there isn’t much in the context of family life that I haven’t encountered. My patch of streets included a mother there are successful interventions that and baby hostel, a travellers’ site and Central can promote parents’ understanding and A DIFFERENT TIME Middlesex Hospital. Mothers knew their prevent the patterns of intergenerational The focus when I trained was on primary health visitor and there was a real sense of relationships and behaviours. Focusing prevention of ill health, and my caseload community, which I felt very much a part of. on the infant-caregiver relationship is the included families with babies and young I attended political events alongside essence of health visiting and I can see children, children and adults with additional militant colleagues to protest against NHS how this focus is changing practice. Health needs, and the elderly. I learned about cuts in the late 1980s, which seems to have visitors are more mindful of babies and their human development from birth to old age. come full circle as I’ve joined similar marches relationships with primary caregivers, and As a registered health visitor in the 1980s, very recently. can support parents in understanding and I worked in Brent focusing on families improving these relationships too. with babies and pre-school children. My REFLECTIONS I refuse to remain anything other than own childhood was in Shropshire – a rural, Families’ needs don’t change and positive hopeful and, despite the cuts and huge farming community – and despite my relationships remain the single most changes ahead, I fi rmly believe that professional training, I had little experience important factor when working with health visitors are the key professionals of cultural and racial diversity. So working people. But I’ve defi nitely witnessed societal in supporting parents to make positive in Harlesden proved a culture shock and a changes. I still remember, because of its changes that will alter their children’s steep learning curve. rarity, the fi rst time I saw a man at a baby trajectory in life. CP My caseload consisted of around 350 clinic. There is more visible poverty, with a families and the local policy at the time rise in homelessness and the use was for health visitors to make contact with of food banks. I sense a lack of trust Nurses protest families every week for the fi rst six weeks within communities – knowing the against NHS cuts at a London rally and monthly thereafter for the fi rst year. I neighbours and supporting each in the 1980s had to see the babies and children during my other has dwindled. visits, even if they were reported asleep in Seeing thousands of healthy babies another room. and children, health visitors knew what ‘normal’ looked like. It concerns me that health visitors are becoming more reactive than proactive and have little I attended political contact to provide that vital preventive support. This lack of exposure could events to protest against result in a lack of confi dence and parents’ NHS cuts in the late anxieties, instead of being ‘normalised’, might be treated as a problem. 1980s, which seems to But having worked for the last fi ve

GETTY have come full circle years in infant mental health, I’m confi dent

MayMaayay 20220170177 ComCoCCommunityomommunmuunityittyty PrPPractitionerractaaccttitiititiioneononeer 2121

21 30 as.indd 21 27/04/2017 12:4 HOW TO

Promote

S A Y As the summer season F T E e all look forward to the rolls around, it’s summer weather and spending more time important to remind outdoors – in theory at ourselves of sun least. But it’s easy to get Wcarried away at the fi rst hint of sunshine and protection guidance forget just how dangerous it can be when and spread the safety our skin is overexposed. With Sun Awareness Week taking place message to children, from 8 to 14 May, what better time to refresh your knowledge about the risks and young people protection measures to promote to children, and families. young people and parents?

22 Community Practitioner May 2017

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KNOWING THE DANGERS SUN SAFETY TIPS Dr Bav Shergill of the British Association of Dermatologists (BAD) says that skin cancer is ● Protect the skin with clothing, including a hat, t-shirt and sunglasses now the most common form of cancer in the ● Spend time in the shade between 11am and 3pm when it’s sunny UK, with rates rising since the 1970s. ● Use a high protection sunscreen of at least sun protection factor (SPF) 30, ‘According to the cancer registries, and which also has high UVA protection, and make sure you apply it generously reported by Cancer Research UK, in 2014 and frequently when in the sun there were 15,419 cases of melanoma – the ● Keep babies and young children out of direct sunlight deadliest form of skin cancer,’ he says. ‘In ● The British Association of Dermatologists recommends telling your doctor total, 2459 died from melanoma that year.’ about any changes to a mole – if your GP is concerned about your skin, make But skin cancer is also very preventable, sure you see a consultant dermatologist (on the General Medical Council register Bav adds, ‘if basic sun protection advice is of specialists). The GP can make a referral through the NHS. followed’. ‘So it’s important that the public is aware of how to check their skin and about good sun protection habits.’ Giving out some sun safety tips to disseminate to families (see box), Bav asserts KEY STATISTICTIC that childhood is a particularly vulnerable time when it comes to sun exposure. ‘A baby’s skin can burn within minutes, which is why it’s so important to keep 15,419 them out of direct sunlight,’ he says. ‘For older children it would not be practical or the number of melanoma cases advisable to try and keep them out of the in 2014 reported by Cancer sun altogether; parents should instead Research UK ensure that their skin is properly protected from getting sunburnt.’ still need some helpp ttoo eneensuresuurer ttheyhey usuusee He continues: ‘It’s worth remembering that enough sun cream.’’ past episodes of severe sunburn, often with And from the teenagenage yyears,ears, inincreasedncreae sed blisters, particularly in childhood, increase peer pressure aroundndn iimagemam gee andandn thethe the risk of developing melanoma. perception that a tanan makesmamakees uss ‘This means it is particularly important to look ‘healthier’ (see myth-bustingmyth-bbusting USING SUNSCREEN make sure that adults supervising children box) can lead to youngung ppeopleeoe plp e are aware of the dangers of excessive sun and adults alike goingng toto unsafeunu sas fe ● Apply enough – people often apply exposure, and that children are encouraged measures to achievee a moremom ree far less than they need. As a guide it to protect their skin against sun damage bronzed look. should be around two teaspoonfuls of from an early age.’ Claire says that att oneone of thethe sunscreen if you’re just covering your high schools she worksoro ks with,witth, theythey head, arms and neck, and around two DYING FOR A TAN? make use of a noticeboard.eboarrd. ‘In‘In tablespoonfuls if you’re covering your Making sure infants are protected from the the summer term wee ddoo a didisplaysplay entire body sun can perhaps be an easier feat than at about sun safety, alcoholcoohol anandnd ● Reapply regularly – even if using ‘once later stages, as school nurse Claire explains. generally keeping safesaafe duringduring thethe a day’ or ‘waterproof’ brands) – it’s ‘As children grow and become more holidays,’ she says. easily rubbed, sweated or washed independent I don’t think they are always It’s also importantnt ththatata ppublicubbliic off . And reapplying helps avoid aware of how important it is,’ she says. health nurses educateatte parentspareents andannd missing areas ●

ISTOCK/GETTY ‘Young children and some older pre-teens young people on thehe potentialpotential Use together with shade and clothing to avoiding getting sunburnt ● Don’t be tempted to spend longer in the sun than you would without sunscreen ● Apply to clean, dry skin ● Check the expiry date – most sunscreens have a shelf life of two to three years.

Source: Cancer Research UK

May 2017 Community Practitioner 23

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dangers of sunbed use, says Bav. MYTH BUSTING He tells Community Practitioner about an Jana Witt from Cancer Research UK reveals the truth behind in-depth analysis of multiple studies that some of the common myths around sun exposure… found using sunbeds before the age of 35 increases the risk of skin cancer by 75%. ‘The same research also found that each ‘Sunscreen is the best way to protect people will sunbed session increased a person’s risk of myself from too much sun’ have a diff erent melanoma by 1.8%,’ he adds. When it comes to protecting your risk of sunburn And another study in 2014 found that, by skin, there’s much more to think about depending on 55 years of age, people who used a sunbed than just sunscreen. Covering up with their skin type. were 90% more likely to develop a squamous clothing, a hat and sunglasses are much Generally in the cell carcinoma – a common type of skin better ways to enjoy the sun safely. UK people with cancer – than those who did not. Sunscreen is best used as a supporting fairer skin are act to protect the bits you can’t cover. at higher risk of ON A BUDGET sunburn, whereas people with darker For families living in areas of deprivation and ‘Tanned skin is a sign of good health’ skin are more likely to have low vitamin struggling with money, it’s understandable No it’s not – a tan is a sign that your D – so it’s good to know your skin type. that suncare products could be perceived skin is trying to protect itself from the as an unaff ordable luxury. Claire says she damage the sun is doing – it’s certainly ‘The sun in the UK isn’t strong enough isn’t aware of local schemes that off er free not a sign of good health. And any to give me sunburn’ sun protection creams, for example, but Bav pink or redness, even if your skin isn’t It can be, especially between March remarks that ‘we’re seeing a wider range of raw or blistered, is a clear sign that the and October. It’s easy to underestimate budget products on sale’. DNA in skin cells has been damaged. how strong the sun can be here and get ‘A cheaper price tag doesn’t mean it’s an Cancer Research UK would like to see caught out. A 2016 survey by Cancer inferior sunscreen: if it off ers an SPF of 30 more people celebrate their natural skin Research UK and Nivea Sun showed that and has good UVA protection, then it doesn’t tone and started the #OwnYourTone more than eight in 10 British people matter about the price,’ he says. ‘If sunscreen campaign to encourage it. have been sunburnt in the UK. is 100% out of the question for budgetary reasons then it’s very important that parents ‘I can’t get sunburnt on cloudy days’ ‘A tan protects my skin from damage’ make use of other sun protection methods, Yes you can – ultraviolet (UV) rays can go A tan only off ers an SPF of around 3 – not such as protective clothing and shade.’ through clouds, so cloudy and even rainy nearly enough to protect yourself from Indeed, the ‘Slip! Slop! Slap!’ campaign days can be deceiving. If it’s overcast sun damage. made famous in Australia in the 1980s, which or if there’s a bit of wind you may also has since been superseded by ‘Slip, Slop, not notice that you’re getting sunburnt ‘I’ve been sunburnt before, so the Slap, Seek, Slide’ to encourage the use of before it’s too late. The UV index can damage is already done’ sunglasses and shade, is worth remembering help you check how strong the sun will Your body’s repair mechanisms aren’t as a safety motto to keep sun safety fresh be on a given day – if it’s 3 or above, the perfect and with every instance of in children’s and families’ minds ahead of sun’s strong enough to cause sunburn, sunburn, damage builds up, increasing summer, and indeed all year round. especially in people who burn easily and/ your risk of skin cancer. But because this Claire remarks that while sun safety or have fair skin. damage is cumulative – rather than a guidance is no longer part of ‘what we’re one-time event – it’s never too late to commissioned to provide’ in her area, she ‘Sunscreen that’s more expensive start protecting yourself. makes every eff ort to ensure the message off ers better protection’ still gets through. ‘We try to make every The most important thing is the SPF and ‘Aftersun products repair the damage contact count and take the opportunity star rating, rather than price or brand. done by sunburn’ of providing health promotion messages In tests by Which? cheaper brands While aftersun products may soothe the whenever we can,’ she adds. CP performed as well as more expensive unpleasant symptoms of sunburn, they ones, and the majority of products won’t fi x any damage that was done to ● For resources and sun safety provided the level of protection the DNA inside your cells. If you notice guidelines from the BAD, go to bit.ly/ advertised on the bottle. your skin starting to go red, seek shade BAD_healthcare_resources; for more and cover up immediately. Don’t spend information on enjoying the sun safely, ‘Dark skinned people don’t get burnt’ more time in the sun that day – even go to bit.ly/CRUK_sun_safety; and to Anyone can get sunburnt – including with sunscreen – and don’t rely on take part in Sun Awareness Week, use people with dark skin. But diff erent aftersun to fi x the damage. the hashtag #SunAwarenessWeek

24 Community Practitioner May 2017

22-24 Sun Protection.indd 24 27/04/2017 12:56 CONFERENCE 2017

As registration for this year’s Unite-CPHVA conference opens, we off er tips on garnering the support of your employer to Easing reap the professional rewards of attending. the way ASKING FOR FUNDING SUPPORT egistration for the Unite-CPHVA the branch can keep an accurate record. conference is now open, and The request is probably best made in If you’re interested in attending this you can benefi t from an early writing to the branch secretary and then year’s conference but are unsure of discount – £166 + VAT for Unite followed up by attending the next branch how to approach your manager to members until 15 May or, if you meeting, where a decision can be made. gain approval, these points could Rmiss this; £205 + VAT until 7 August. You could make this request individually or help you put forward a winning case: In the meantime, why not start the as a group, and if you have a Unite-CPHVA process of requesting funding support and local accredited representative (LAR) in ● I’ll have access to a dedicated securing approval from your employer in your team, they could make the request. conference programme specifi cally time to benefi t from these rates? And, if no one in your team is an LAR, aimed at community practice perhaps now is a good time to step up! ● I’ll be able to network and share FUNDING FROM UNITE BRANCHES If you decide to seek funding help to get experiences with community It might be possible to receive fi nancial to conference, best of luck and we hope to practitioners from across the support from your Unite branch too, see you there in October. CP UK and bring back transferable especially if you attend branch meetings information to develop our work and keep up to date with what they’re ● To register and for more details ● It will support revalidation with doing. Each branch has funds to be used on this year’s conference, go to plenary sessions, masterclasses where it considers appropriate, and cphvaconference.co.uk; and to and best practice workshops supporting members to attend conference contact your regional offi ce, go to ● I’ll hear policy updates on the latest could be something they consider. bit.ly/Unite_health_regional regulatory challenges aff ecting our If you don’t already know the details services and our clients of your local Unite branch secretary then ● I’ll be able to bring back useful your local regional offi ce will be able to insights to share with the rest of help you out. You can then get the team in touch and outline what ● Early discount tickets the conference is about are available until 7 (see box) and the support August, saving up to you’re seeking. A good plan £103 off standard is to ask for something that prices, so the earlier can be evidenced with I book the more can a receipt – such as the be saved. ticket cost, travel or accommodation – so You should be asking for time off to attend, as well as funding Unite-CPHVA for the ticket Annual Professional – you may not Conference 2017, get both, but Cardiff Motorpoint it’s always Arena, 17-18 worth asking. October ISTOCK

May 2017 Community Practitioner 25

2 ttin to onn 2017.indd 2 27/04/2017 12:6 The Unite-CPHVA Annual Professional Conference 2017

17th–18th October 2017 Motorpoint Arena Cardiff

Energise. Educate. Empower. Registration now open.

The last year has been full of challenges for community practitioners. More than ever, it is important to feel the support of your colleagues and keep ahead of the ever-changing political and professional landscape.

Book your ticket today and join us in Cardiff this October.

Don’t miss out on Super Early Bird rates – available until 15th May 2017!

To book visit: cphvaconference.co.uk/registration

p26-27.CPMAY2017.indd 26 26/04/2017 11:38 Why visit the Unite-CPHVA Annual Professional Conference?

Whether you are a health visitor, a nursery nurse, community nursing practitioner or school nurse, educationalist, researcher or student there is something of interest for everyone on the programme.

What will you gain? • Access to a dedicated programme and exhibition • Opportunities to network and share experiences • A choice of break-out sessions and masterclasses • The chance to hear inspirational success stories from your peers • Time to reflect on and develop your skills • Clinical and professional updates to support your CPD and revalidation • A social event where you can relax with friends

Tickets start at just £166+VAT* – don’t miss out [The highlight for me] was meeting on savings, book today! like-minded people, sharing best cphvaconference.co.uk/registration practice and obtaining information...” Health Visitor, 2016 attendee *Discounts available for students, CNNs, and school nurses

p26-27.CPMAY2017.indd 27 26/04/2017 11:39 COVER FEATURE

MICR

Are antibiotics becoming a n March, health secretary Jeremy Hunt apologised to the family of one-year-old William Mead, who died of healthcare catastrophe? septicaemia in 2014. Attending the memorial service, Mr Lorna Duckworth explores Hunt said: ‘I as health secretary, the government, and the NHS, let down William. I’ve come here to say sorry. We how real a problem didn’t spot his sepsis before it was too late.’ antimicrobial resistance is, its When diagnosed quickly, sepsis can be treated with antibiotics. But the early symptoms (see box on page 30) can be mistaken for implications for public health infl uenza or other infections and the report following William’s death accepted that doctors are under pressure not to prescribe and future generations, and antibiotics. It’s unusual for a cabinet minister to apologise, but what community practitioners the statement from Mr Hunt illustrates the diffi culties and risks can do to tackle it. that surround antibiotic use. REALITY CHECK So what’s being done about it? In the north-west of England, where antibiotic use is higher per head than in any other region,

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SCOPE

a media campaign to warn the public about the dangers of taking hard to take the threat seriously.’ antibiotics unnecessarily has been undergoing a two-month trial. The TV and radio adverts in the North West – backed by The ‘Keep Antibiotics Working’ campaign will be rolled out publicity materials in GP surgeries, pharmacies, children’s centres nationally by Public Health England (PHE) as part of the ongoing and local authorities – don’t sugar-coat the message, using battle against drug-resistant infections. Alongside it will be a new statements such as: ‘Unless we act fast and together we are going focus on infections caused by Escherichia coli (E. coli), which have to enter an era where no antibiotics work,’ and ‘Imagine no more been rising at an alarming rate and are showing increased levels of heart, bowel or bone operations; no more cancer treatment. This resistance to antibiotics. is where we are headed.’ But the threat posed by antimicrobial resistance is not an And they’re right: as the range of eff ective antibiotics becomes easy message to sell. Antibiotics have worked well for decades, more limited, illnesses will last longer, require lengthier hospital curing all kinds of illness and saving countless lives. Ros Godson, stays and carry a greater risk of death. Similarly, procedures to lead professional offi cer for public health at Unite-CPHVA, says: treat cancer such as chemotherapy, organ transplants, caesarean ‘The diffi culty is getting people to take antimicrobial resistance sections and hip replacements will become far riskier if the seriously. Most of us don’t have friends with resistant infections, protection off ered by antibiotics continues to be compromised. and we don’t see the problem in our daily lives. Until we get In England, around 5000 people are thought to die each year children on our caseloads dying of resistant infections or until we because antibiotics no longer work against some infections. The

SCIENCE PHOTO LIBRARY PHOTO SCIENCE get old people routinely dying of drug-resistant pneumonia, it’s 2015 Review on antimicrobial resistance, chaired by Lord O’Neill,

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forecast that drug-resistant infections could really take when you absolutely need to... claim 10 million lives each year worldwide by because if you take them when you don’t 2050 without action to halt their spread. RECOGNISING SEPSIS need to, say for trivial infections such as a cold, which is likely to be caused by a virus TACKLING OVERCONSUMPTION Known as the ‘silent killer’, sepsis anyway, then not only will they have no Antibiotic consumption is a major factor is thought to aff ect benefi t, but you may suff er side eff ects and behind the rise of antimicrobial resistance: end up harbouring resistant bacteria.’ areas with high levels of antibiotic prescribing have high levels of resistance. REDUCING PRESCRIPTIONS In the North West, from April to June 2016, More than 75% of antibiotics in England are more than 1.2 million courses of antibiotics prescribed in general practice and other were prescribed, the most per head of any community settings. To reduce inappropriate UK region. Merseyside had the highest rate prescribing in general practice, fi nancial of antibiotic use, with consumption 30% incentives were introduced to reward clinical higher than Thames Valley, which had the commissioning groups that meet annual lowest use in England in 2014. 150,000 targets to cut total antibiotic prescribing and PHE is investigating why some areas have people in the UK each year and the use of broad-spectrum antibiotics. These higher antibiotic use than others; the answer cause at least ‘last line’ antibiotics act against a wide range is likely to be multifactorial, with reasons of bacteria and should ideally be reserved including general levels of health and for tackling the most serious, hard-to-treat co-morbidity, smoking rates, ethnicity and bacterial infections. deprivation in a population. 44,000 As a result, the number of prescriptions But what is to be done? Educating issued by general practice in England fell by the public about the use of antibiotics 7.3% – or 2.6 million fewer prescriptions – in is one area where health visitors, school 2015-16 and the use of broad-spectrum nurses and community nursery nurses DEATHS antibiotics went down 16% to 3.3 million have considerable infl uence. They can prescriptions from 3.9 million the previous encourage parents to trust their doctor if In the early stages, it can be mistaken for year. Antibacterial use has also declined in they advise that a child doesn’t require an a chest infection, stomach upset or fl u. Wales, while Scotland, which has been a If antibiotics are given quickly, sepsis antibiotic. Should the child fail to get well, forerunner, has seen annual decreases in can be eff ectively treated. NHS Choices they can ensure the doctor is consulted recommends that parents go to A&E antibiotic prescribing since 2012 because of again. If antibiotics are prescribed, they or call 999 if a child under fi ve looks better antibiotic prescribing practices. can underline that the entire course needs mottled, bluish or pale, is lethargic or to be taken exactly as prescribed. Taking diffi cult to wake, feels abnormally cold, UTIs ON THE RISE is breathing very fast, has a rash that antibiotics when it’s not necessary, or using A new goal to halve the number of doesn’t fade when pressed or has a fi t. them incorrectly, can encourage bacteria bloodstream infections caused by E. coli and inside the gut to become resistant, making The UK Sepsis Trust identifi es these six other gram-negative bacteria by 2021 was antibiotics less likely to work a second time. warning signs: announced by Jeremy Hunt in November. Professor Alan Johnson, head of PHE’s ●Slurred speech or confusion More than a third of all bloodstream ●Extreme shivering or muscle pain department of healthcare-associated infections are caused by E. coli. NHS trusts ●Passing no urine in a day infection and antimicrobial resistance, and ●Severe breathlessness reported more than 38,000 cases in 2015-16 a member of the government’s advisory ●Death-like feelings (an 18% increase on 2012-13) and more than committee on antimicrobial prescribing, ●Skin that’s mottled or discoloured. 5500 patients died that year. resistance and healthcare-associated E. coli infection rates have increased infection, says: ‘Antibiotics are totally unlike with rising levels of resistance. Septicaemia other drugs used in human medicine is more likely to be fatal in the very for the simple reason that the young, the old, people who have more you use them, the less an underlying infection or eff ective they become. respiratory illness, and ‘They really do need people who acquire the to be regarded by infection in hospital. patients and the Infections caused public as a special by strains that type of drug that are resistant to you should only carbapenem

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antibiotics are a particular concern. for treating serious bacterial infections, such Nearly 1900 cases of infection caused as pneumonia, meningococcal meningitis by carbapenemase-producing and sepsis, they continue to be prescribed Enterobacteriaceae were confi rmed in for everyday viral infections, such as colds UK laboratories in 2015. or fl u, despite being ineff ective. There are Guidance will shortly be issued about concerns that the rise of antimicrobial how the health service can reduce E. coli resistance in children could render some bacteraemia. Many of the initiatives will antibiotic treatments ineff ective. involve action in the community, particularly When given repeat prescriptions of in relation to the diagnosis, treatment and antibiotics, children are at increased prevention of urinary tract infections (UTIs), risk of being colonised by a drug- which are commonly caused by E. coli. resistant pathogen, leaving them UTIs have an important link with E. coli vulnerable to future infection that bloodstream infections. Research suggests could make them poorly for longer that 50% of patients who contract an E. coli and more diffi cult to treat. Research bloodstream infection have an underlying published last year shows that children urinary tract infection or colonisation that is who are treated for UTIs caused by E. the root cause. Therefore, in order to reduce coli have a greatly increased risk of a the more serious bloodstream infections, further infection being drug-resistant in which require hospital treatment, it makes the three months after taking antibiotics. sense to tackle community UTIs at the Professor Dilip Nathwani, consultant same time. physician in infectious diseases and But infection control specialists question honorary professor of infection at Ninewells whether the goal to halve E. coli bloodstream Hospital and Medical School in Dundee, infections by 2021 is realistic and the increase says a quarter of all drugs prescribed in drug-resistant E. coli and other gram- to children are antibiotics. ‘We need to negative bacteria is causing concern across think what we’re doing when we give the world. In a recently published list of 12 children repeated courses of antibiotics. families of bacteria that pose the greatest Our relationship with antibiotics needs to threat to human health (see box), the WHO change,’ he adds. ranked Enterobacteriaceae, the family of Health visitors and community nurses, bacteria that includes E. coli, in the critical while in conversation with mothers and group for which new antibiotics need to be most urgently found. 12 MOST RESISTANT BACTERIA THE NEXT GENERATION Bacteria in order of priority and the antibiotics to which they are resistant Meanwhile, evidence is growing about the impact that overexposure to antibiotics has PRIORITY 1: CRITICAL as gonorrhoea and food poisoning. on children. While antibiotics are important Includes multi-drug-resistant Enterococcus faecium – vancomycin bacteria that pose a threat in Staphylococcus aureus – methicillin hospitals, nursing homes and and vancomycin among patients whose care requires Helicobacter pylori – clarithromycin devices such as ventilators and blood Campylobacter spp. – fl uoroquinolone catheters. They can cause severe Salmonellae – fl uoroquinolone and often deadly infections such as Neisseria gonorrhoeae – cephalosporin septicaemia and pneumonia. and fl uoroquinolone Acinetobacter baumannii – carbapenem Pseudomonas aeruginosa – carbapenem PRIORITY 3: MEDIUM Enterobacteriaceae (includes E. coli) Streptococcus pneumoniae – penicillin- – carbapenem non-susceptible Haemophilus infl uenzae – ampicillin 5000 PRIORITY 2: HIGH Shigella spp. – fl uoroquinolone people are thought to die each Increasingly drug-resistant bacteria year because of antibiotics that no that cause more common diseases such Source: WHO

ISTOCK longer work against infections

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other family members, could play a vital role allow a doctor to take a in explaining not only the importance of simple, four-minute test immunisation, but why antibiotic use needs to see if an illness is likely to be restricted. The role of vaccinations to respond to antibiotics in preventing infections that would need to be made more otherwise require antibiotics, should not widely available. be underestimated, Professor Nathwani The C-reactive protein explains. ‘I think they have a wonderful blood test, for example, opportunity to have that conversation and, can help a doctor determine in broad terms, outline that most fevered whether a patient with a chest illnesses that the child will get are viral infection has a normal respiratory infections not bacterial and do not require infection that will resolve on its own or an antibiotic,’ he says. a more serious infection like pneumonia Professor Nathwani, who is president and should be treated with antibiotics. of the British Society for Antimicrobial Without a chest X-ray, pneumonia can be Chemotherapy and past chair of the diffi cult to diagnose. The blood test assists Scottish Antimicrobial Prescribing Group, the clinical decision-making process and can says there was increasing evidence, from avoid the unnecssary use of antibiotics. scientifi c papers in journals like Nature, Professor Nathwani says: ‘We have piloted to suggest antibiotics could disrupt the the test in 10 general practices across RESOURCES normal microbiota (the useful bacteria in the Scotland and they found it very valuable. bowel) to such an extent that children could The problem is getting it funded so that it TARGET provides guidance potentially be predisposed to obesity or is used widely.’ about when and what antibiotics other conditions later in life. It seems that a concerted eff ort among to prescribe and leafl ets to ‘If you give a child a certain type of healthcare professionals to educate share with clients. Go to antibiotics or repeated courses, there’s the public and to reduce antibiotic bit.ly/RCGP_TARGET condition called dysbiosis in which the consumption where it isn’t necessary balance of the bowel fl ora will change could see the beginnings of a fi ght against The Antibiotics for Children webinar quite dramatically. In many cases, this the very real problem of antimicrobial gives advice about how to identify will recover after the course of antibiotics, resistance, but there’s no doubt the road an unwell child and whether they but in a signifi cant proportion of children ahead is long. CP require antibiotics. For more it is very slow or may not recover, and bit.ly/TARGET_webinar that could predispose a child to allergies, obesity and a whole range of conditions NICE guidance for prescribing like type 1 diabetes, rheumatoid arthritis antibiotics to children, young and bowel disease. people and adults with self-limiting ‘This impact of antibiotic use outside respiratory tract infections. Visit infections is not well recognised and worth bit.ly/NICE_cg69 thinking about.’ Educational material and games PREVENTATIVE MEASURES to help children understand how In terms of practical methods to reduce infections spread and antimicrobial antibiotic use, Professor Nathwani says resistance develops. To read on deferred prescriptions, where doctors e-bug.eu give a parent a prescription that can be held in reserve and used only if a child 2.6 million Sign up to be an ‘antibiotic guardian’ fails to recover, were a useful way to and improve knowledge of resistance fewer antibiotic prescriptions were reduce pressure on doctors to prescribe. issued by general practice in England at bit.ly/Antibiotic_guardian

In addition, rapid diagnostic tests that during 2015-16 ISTOCK

32 Community Practitioner May 2017

2-32 o to.indd 32 27/04/2017 12: Getting to the bottom of nappy rash

Most babies get nappy rash at some time and around a third of nappy wearing infants are likely to have nappy rash at any one time1.

THE METANIUM RANGE – HERE TO HELP Metanium Everyday Easy Spray Barrier Lotion is the latest addition to the Metanium family. In a handy, easy-to-use spray, Metanium Everyday Easy Spray forms a barrier to protect delicate skin from irritants like urine and faeces that can cause nappy rash. Two sprays should be enough to protect the skin to form a thin protective layer. Pat around the area to maximise coverage. No need to rub in. Easy Spray has a unique, water-free formulation to create an effective barrier against irritants. Both urine and faeces contain water, so any water-based formulation is unlikely to offer sufficient protection from nappy rash. Metanium Everyday Barrier Ointment has both a protective and moisturising formula to provide daily protection from nappy rash and is gentle enough to use every day and at each nappy change. If nappy rash does strike, then Metanium Nappy Rash Ointment is licensed specifically to treat nappy rash. Metanium Nappy Rash Ointment is a medicine and is listed on the Nurse Prescribers’ Formulary for Community Practitioners. Most cases of nappy rash only cause mild symptoms and the community It’s usually a mild condition which can easily be treated, but practitioner has a valuable role to play in advising parents about skincare understandably may be a worry to parents. The key feature of nappy rash is routines, as well as prescribing or recommending an appropriate barrier a pink or red rash around the nappy area. ointment. There are a number of ‘trigger’ times when infants are particularly prone to nappy rash. A survey identified seven ‘trigger’ times when parents believed their child was more prone to nappy rash1.

NAPPY RASH TRIGGER TIMES • Teething • Diarrhoea • A cold • First sleeping through the night • Weaning onto solid foods • Antibiotic use • A change in diet like switching to a different type of milk

Being aware of these ‘trigger’ times means that parents can take steps to help prevent nappy rash occurring.

SKINCARE ADVICE Good skincare advice has a key role in both treating and preventing nappy rash. Recommending these simple steps will help1: FREE SAMPLE OF METANIUM EVERYDAY • Lay your baby on a towel and leave your baby’s nappy off when you can AND A HANDY MEMO PACK! FREE • Change wet or soiled nappies as soon as possible Request a free sample of Metanium Everyday HANDY • Clean the nappy area using plain water or alcohol / fragrance free wipes Barrier Ointment and receive a Memo Pack* MEMO containing a note pad, pen and • Gently pat rather than rub your baby’s bottom dry PACK! post-it notes! • Use a suitable barrier ointment at each nappy change Email your contact details to: Most mild cases of nappy rash can be easily treated with a combination of [email protected] good skin care and the use of an appropriate barrier ointment. *while stocks last.

References 1. Morris H, Getting to the bottom of nappy rash, Community Practitioner, November 2012, Volume 85, Number 11 www.metanium.co.uk

p33.CPMAY2017.indd 33 26/04/2017 11:40 SUPERVISION VALUE-ADDED

he district nursing workforce is under increasing pressure as the number of older people needing care within our communities who have long-term conditions rises. T And the care being delivered is often complex and can be challenging to deliver. A range of factors is causing this rise in Jo Ward and Janet INTEGRATED APPROACH demand: the population is ageing but these The need to ensure clinical supervision are not necessarily healthy years. Data from Durrans describe a is a regular feature in practice has been Cheshire West and Chester in 2014 suggests widely recognised. At Cheshire and Wirral that people living in the area will spend project to implement Partnership (CWP) Trust, the supervision between 14 and 16.3 years living in ‘not so integrated clinical aim is to build a culture of integrated clinical good’ health. supervision and values-based refl ective But it could be argued that this fi gure is supervision at Cheshire practice. To achieve this cultural shift, each likely to be signifi cantly higher in the most and Wirral Partnership community care team has divided staff deprived wards within the borough, which into mixed-discipline supervision groups of has lower life expectancy. The number of NHS Foundation Trust, between fi ve and eight staff . people in the community with multiple or If teams don’t carve out regular clinical long-term complex conditions is increasing which has resulted in supervision refl ection into the fabric of constantly. Life expectancy in some of better outcomes for who they are, they risk outcomes such the wards within Chester and Cheshire as raised sickness levels, staff burnout, West is extremely poor, with clear health staff and patients alike. recruitment and retention issues, team inequalities between wards that are often dynamic issues and increased risk around in close proximity. clinical governance. The model enables Data from the local health profi le in 2015 quality improvement is a key measure for professional groups to explore diff ering roles showed that, across the borough’s 46 wards, commissioner targets. and responsibilities in a safe and confi dential there is a diff erence of 10.1 years in life A recent report by The King’s Fund (2016) context as part of an integrated team. expectancy in males and 7.9 years in females. highlights the impact of the pressures on Integrated values-based supervision The borough faces continued challenges quality of care on the workforce. It explores to reduce rates of circulatory diseases and the dwindling numbers of community cancer, while deaths from liver disease and nurses and the detrimental eff ect this is Each community lung cancer have been increasing within having on staff health and wellbeing. care team has Cheshire’s most deprived communities. It can be exceptionally hard for divided staff into mixed discipline practitioners to make time to refl ect on the supervision COMPLEX NEEDS care they deliver when patient demand is groups of Against this backdrop, the community surging. But doing so is as important as the between nursing and allied healthcare workforce is physical care being delivered and is essential tasked with delivering complex care to some for staff ’s resilience and emotional health of the area’s most vulnerable individuals. and wellbeing. The need to have regular Such episodes of care are often delivered clinical supervision and build a culture of FIVE and when a patient’s illness is traumatic. And refl ective practice is a key part of working the expectation for teams to meet the more eff ectively together as an integrated rise in demand and strive for continuous team (Carpenter et al, 2012). EIGHTstaff

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CHESHIRE WEST AND CHESTER STATISTICS

Deprivation lower 545 than average, but smoking-related deaths per year 15.4% 58.3 per 100,000 of children here the number of people killed live in poverty and seriously injured on roads, population in 2015 which is above national average 331,000 68.5% of adults classifi ed as overweight or obese

doesn’t seek to replace individual or emerge from this process was the need to management supervision; it’s about review clinical supervision. The brief was to strengthening the culture within teams embed a values-based model into all of the to work together in the best interests trust’s community care and specialist teams, of the patient. The trust received support including the continence, tissue viability, from William Jackson at Edge Hill end-of-life, Parkinson’s and out-of-hours University and Ian Hall from Crossley Hall district nursing services. A series of one-hour Associates to create a number of refl ective clinical supervision workshops was designed practice templates that staff could use in to engage staff and build interest and supervision sessions. CLINICAL SUPERVISION: motivation. Following the workshops, each The templates ensure the sessions remain KEY MESSAGES team is supported to ‘road-test’ the concept patient focused, and each closes with a set of in small integrated groups. actions. They were developed to follow both ● Embedding an integrated clinical The project continues to be well received Gibbs’ (1988) and Driscoll’s (2006) refl ective supervision model into community by staff , who are keen to build a supportive practice models, enabling practitioners to care teams is challenging in the framework into their teams. While the work explore thoughts, feelings, behaviours, what current climate has encountered challenges due to surging worked well or needs improving and what it ● Teams need time to develop a clear demands on the community teams, it has means to individuals or the integrated team. vision of roles and responsibilities nonetheless been evaluated positively. And at the end of each session the facilitator ● Integrated clinical supervision Staff are recognising the benefi ts of re-engages the group with the values of care, needs to be implemented carefully learning from each other and report feeling compassion, competence, communication, ● Clinical supervision is essential to positive that the sessions can make a courage and commitment. This is particularly the whole community care team diff erence to patients and their own health empowering for staff . if a clear vision and focus is to be and wellbeing. And having a mechanism for reached and maintained around action-based sessions helps empower staff ‘DEEP DIVE’ PROJECT integrated working to have a voice and challenge practice at a Last year, CWP Trust embarked on a journey ● Group-based clinical supervision time when resilience is shown to be poor. CP to strengthen clinical supervision activity also enables ‘temperature checks’ within physical health integrated teams. on staff resilience levels REFERENCES Carpenter J, Webb C, Bostock L, Coomber C. (2012) SCIE Research ● The journey is ongoing in the form of a Trusts should look beyond the briefi ng 43: eff ective supervision in social work and social care. commissioned project, in which targeted usual data reporting system for See: scie.org.uk/publications/briefi ngs/briefi ng43 (accessed 26 support is being given to community care clinical supervision to capture a April 2017). Driscoll J. (2006) Practising clinical supervision: a refl ective approach and specialist teams to build an integrated qualitative picture of refl ective for healthcare professionals. Baillière-Tindall: Kent. refl ective practice culture. practice and innovation, and Gibbs G. (1988) Learning by doing: a guide to teaching and learning The trust commissioned a ‘deep dive’ consider exploring staff resilience methods. FEU: London The King’s Fund. (2016). Understanding quality in district nursing review that explored the challenges within levels regularly within local teams. services. See: kingsfund.org.uk/publications/quality-district-nursing district nursing. One piece of work to (accessed 26 April 2017).

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34-3 istit nusin 2.indd 3 27/04/2017 1:22 VACCINATIONS IMMUNISATION: Is immunisation slipping does it need a down the health visiting agenda? Helen Bedford, professor of child public health, BOOSTER? explores the evidence.

mmunisation is powerful: it is not only children under fi ve (Public Health England October 2014 and December 2016 (PHE, cost-saving for society and the NHS, but (PHE), 2016a). This will be increased to 14 in 2017b; PHE, 2015). it spares individuals and their families September, with the addition of a universal Whether this reported decline in uptake the misery of diseases that may result in hepatitis B vaccine (PHE, 2017a). Infants is real, and fewer children are being severe consequences or even death. will be off ered a hexavalent vaccine (DTaP/ immunised or whether this is a refl ection of IIn addition, if suffi cient individuals IPV/Hib/HepB) at eight, 12 and 16 weeks to data quality issues is unclear. Either way, it are immunised, diseases cannot spread replace the fi ve-in-one vaccine. serves as a reminder that we can never take and so even those in whom vaccines are Overall, uptake rates are very high and high immunisation rates for granted. contraindicated due to their age, or medical most diseases are now eliminated (polio), While the promotion of immunisation condition, are protected by community occur very rarely (tetanus, diphtheria) or is a core component of the Healthy Child (herd) immunity. But immunisation is have reduced dramatically in incidence Programme (Department of Health, 2009) also a victim of its own success because (Hib, meningitis C, pneumococcal disease, and thus is the responsibility of health as diseases become vanishingly rare, we rotavirus infections, rubella). But a few visiting teams, in the new 4-5-6 model it tend to forget how severe they can be, and (measles, mumps and pertussis) continue to has lost its prominence. And in spite of its people become complacent about the need cause outbreaks. So it’s cause for concern importance and eff ectiveness in protecting for immunisation, thus posing a threat to that there has been a modest decline of less children’s health, promoting immunisation continued success. than 1% in uptake rates recently – in the UK receives relatively few mentions in Public The UK has a highly successful programme the uptake of DTaP/IPV/Hib at 12 months Health England’s guidance for local with protection against 13 diseases for dropped from 94.5% to 93.8% between authorities and providers in commissioning and delivering children’s public health services (PHE, 2016b).

PARENTS’ VIEWS For the past 20 years in England the Department of Health and subsequently PHE have conducted regular surveys of parents to inform the vaccination programme. A key recent fi nding is that the proportion of parents who report discussing immunisation with a health visitor has declined signifi cantly from 52% in 2010 to 34% in 2016 (PHE, unpublished). While the reasons for this are unclear, it may be the result of immunisation administration now being largely a responsibility of practice nurses. And the apparent demotion of the importance of

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immunisation in the ‘high-impact areas’ of health of children by sidelining this highly health visiting will certainly not be helping. eff ective and cost-saving intervention. CP In a recently conducted focus group, 20 KEY STATISTICS mothers of young babies in London talked REFERENCES about their experiences of the immunisation Benin AL, Wisler-Scher DJ, Colson E, Shapiro ED, Holmboe ES. (2006) Qualitative analysis of mothers’ decision-making about process. All recognised the importance of vaccines for infants: the importance of trust. Pediatrics 117(5): immunisation but many felt they had not 1532-41. been given adequate information. But they Campbell D. (2016) Babies missing out on key checks after fall in 14 health visitor numbers. See: theguardian.com/society/2016/ also mentioned forgetting whether their The number of diseases protected dec/08/babies-missing-out-on-key-checks-after-fall-in-health- health visitor had talked to them about by vaccines from September visitor-numbers (accessed 19 April 2017). immunisation at the new baby review Campbell H, Edwards A, Letley L, Bedford H, Ramsay M, Yarwood J. (2017) Changing attitudes to childhood immunisation in English visit because of feeling overwhelmed by parents. Vaccine (in press). information at that stage. They expressed Department of Health. (2009) Healthy Child Programme: Pregnancy The proportion of parents the need for more information on what they and the fi rst fi ve years of life. See: gov.uk/government/publications/ discussing immunisation with a healthy-child-programme-pregnancy-and-the-fi rst-5-years-of-life considered an important topic, with many health visitor dropped from (accessed 19 April 2017). reporting turning to the internet but fi nding Leask J, Kinnersley P, Jackson C, Cheater F, Bedford H, Rowles G. (2012) Communicating with parents about vaccination: a it diffi cult to identify credible sources. framework for health professionals. BMC Pediatrics 12: 154. It is also recognised that parents have Public Health England. (2015) Quarterly vaccination coverage diff ering information requirements, in statistics for children aged up to fi ve years in the UK (COVER to programme): October to December 2014. See: gov.uk/government/ part determined by their position on 52% 34% uploads/system/uploads/attachment_data/fi le/420876/hpr1115_ immunisation (Leask et al, 2012). While COVER_v4.pdf (accessed 19 April 2017). most parents immunise their children Public Health England. (2016a) Routine childhood immunisations from summer 2016. See: gov.uk/government/uploads/system/ automatically (Campbell et al, 2017), others in 2010 in 2016 uploads/attachment_data/fi le/533863/PHE_2016_Routine_ have concerns and questions that need Childhood_Immunisation_Schedule_SUMMER2016.pdf (accessed 19 April 2017). to be thoroughly addressed with detailed controversy, pockets of lower uptake persist, Public Health England. (2016b) Supporting public health: children, information before they will accept it. with many older teenagers and young adults young people and families. See: gov.uk/government/publications/ commissioning-of-public-health-services-for-children (accessed When parents have doubts about remaining unvaccinated. 19 April 2017). immunisation, advice from a trusted health Recent outbreaks of measles have largely Public Health England. (2016c) Early years high impact area 5: professional can be pivotal in their decision involved these older age groups (PHE, managing minor illness and reducing accidents. See: gov.uk/ government/uploads/system/uploads/attachment_data/ making (Benin et al, 2006). In England, 2016e). But unvaccinated children of all ages fi le/563925/Early_years_high_impact_area5_managing_minor_ parents report health professionals and the remain at risk and last year a 10-month-old illness.pdf (accessed 19 April 2017). NHS to be their most trusted source of advice baby, too young to be immunised, died Public Health England. (2016d) Early years high impact area 6: health, wellbeing and development of the child aged two: two year on immunisation (Campbell et al, 2017). because of complications of measles (PHE, old review. See: gov.uk/government/uploads/system/uploads/ Although practice nurses administer most 2016f). This provides a sharp reminder of the attachment_data/fi le/563926/Early_years_high_impact_area6_ health_and_wellbeing_at_2.pdf (accessed 19 April 2017). vaccines, appointment slots of only 10 to importance of maintaining a high uptake Public Health England. (2016e) Laboratory confi rmed cases of 15 minutes are common for immunisation, of vaccines, and while uptake is fairly stable measles, mumps and rubella, England: July to September 2016. See: gov.uk/government/uploads/system/uploads/attachment_data/ leaving little or no time to discuss in UK, other international events pose a fi le/572733/hpr4116_mmr.pdf (accessed 19 April 2017). concerns. Health visitors are ideally placed potential threat. Public Health England. (2016f) Laboratory confi rmed cases of to provide this advice at the mandated For example, in the US, where measles, mumps and rubella, England: April to June 2016. See: gov. uk/government/uploads/system/uploads/attachment_data/ antenatal contact (Bennett, 2017) – an ideal immunisation is a requirement for fi le/544284/hpr2516_mmr.pdf opportunity not only to check that women school entry, an increase in non-medical Public Health England. (2017a) Change of vaccine for routine have been off ered fl u and pertussis vaccines exemptions has been reported, which primary baby immunisation programme. See: gov.uk/government/ uploads/system/uploads/attachment_data/fi le/608537/Vaccine_ in pregnancy but to introduce information has been explained by increasing ‘vaccine Update_261_April_2017_.pdf (accessed 19 April 2017). on the infant vaccines, thus giving parents hesitancy’ (Salmon et al, 2015). And despite Public Health England. (2017b) Quarterly vaccination coverage time to consider the issue before the birth. substantive evidence of no link between statistics for children aged up to fi ve years in the UK (COVER programme): October to December 2016. See: https://www.gov. MMR vaccine and autism (Taylor et al, 2014) uk/government/uploads/system/uploads/attachment_data/ THE ROLE OF HEALTH VISITORS and no new credible evidence suggesting fi le/605015/hpr1317_COVER2.pdf (accessed 19 April 2017). Public Health England (Bennett V). (2017c) Mandation to continue Nineteen years ago, a now discredited a link, claims to the contrary have been for universal service fi ve health visiting contacts: supporting the paper in The Lancet that was interpreted as encouraged recently by tweets from best start in life. See: https://vivbennett.blog.gov.uk/2017/03/01/ mandation-to-continue-for-universal-service-fi ve-health-visiting- showing a link between MMR vaccine and President Trump. contacts/ (accessed 19 April 2017). autism and bowel disease triggered a major And while reductions in public health Salmon DA, Dudley MZ, Glanz JM, Omer SB. (2015) Vaccine vaccine controversy. In the UK, MMR vaccine spending have placed health visitors under hesitancy: causes, consequences, and a call to action. Vaccine 33: D66-71. uptake fell and although overall uptake great pressure with larger workloads and Taylor LE, Swerdfeger AL, Eslick GD. (2014) Vaccines are not among young children has now recovered increasingly complex cases (Campbell, 2016), associated with autism: an evidence-based meta-analysis of c ase-control and cohort studies. Vaccine 32(29): 3623-29.

ISTOCK and is indeed higher than before the it would be a tragedy if we jeopardised the

May 2017 Community Practitioner 37

36-37 Immunisation V2.indd 37 27/04/2017 13:01 EARLY INTERVENTION Raising the bar In response to t is well recognised that a child’s early experience and environment infl uences heightened needs in their brain development during early The aim is to improve Devon, a programme of years, when warm and positive parenting helps to create a strong foundation for health outcomes and intensive health visiting the I future (Department of Health (DH), 2011). reduce inequalities by As Allen (2011) states, early intervention working in partnership is delivering tailored ‘off ers our country a real opportunity to early interventions to make lasting improvements in the lives of with women, their our children’ that can result in ‘long-term partners and babies vulnerable families. savings in public spending’. Victoria Howard, In a bid to off er the early intervention approach to families in Devon, a model needs assessment. But when the additional Lee Beardsmore and of intensive health visiting has been visits were made, there was no framework developed, drawing on the existing skills of to measure the health visiting interventions Elaine O’Flaherty from the workforce and established partnerships and subsequent outcomes. the Virgin Care team with other agencies. The model was named the Devon Health Visiting in Partnership HIGH RISK, LOW PROTECTION describe the project. programme (DHViP) and plays an important The overall aim was to create a framework part of the Healthy Child Programme (DH, of intensive health visiting incorporating a 2009), which acknowledges how vital the progressive, universal service around the early months of pregnancy and infancy are fi ve core contacts and focusing on high- for babies’ brain development. The aim of impact areas to reduce inequalities, to be the DHViP is to improve health outcomes delivered within the existing workforce and reduce inequalities by working in and budget. This is highlighted within the partnership with women, their partners and Healthy Child Programme (DH, 2009), which babies to help build confi dence and improve encourages focus on the most vulnerable knowledge around good parenting, health children where risk factors are high and and positive relationships. protective factors are low. As a result, a total At the start of the DHViP development in of 24 planned home visits were scheduled 2014, it was recognised by the public health covering a two-and-a-half-year period. team leaders working in Devon that many These visits are categorised as episodes of practitioners were visiting families over care (see box). and above the mandated fi ve core contacts The initial work for the steering group outlined by the Healthy Child Programme involved researching intensive health visiting (DH, 2009) and the Health Visiting programmes across the country. These Programme (NHS England, 2011), due to the included the family nurse partnership and level of need identifi ed by a family health the maternal early childhood sustainable

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home visiting programme. Both schemes It was also decided that the caseload for are recognised, evidence-based, intensive health visitors should initially be no more programmes focusing on early intervention KEY FACTS than one family per day the practitioner strategies to change life outcomes for worked, and that the addition of a DHViP families and children. family should be discussed with the team A common feature of these programmes leader prior to the family being accepted is family partnership model (FPM) training, 24 onto the programme. which focuses on working in partnership planned home visits were scheduled with families, building strength and over a two-and-a-half-year period MEASURING OUTCOMES resilience. As a result, FPM training was Early input and discussion in the antenatal delivered to 40 of the 120 health visitors in period with families has been found to Devon. While the training was rated by staff be an important foundation for the rest as useful to practice, it was not deemed of the DHViP. With the antenatal contact essential to the roll-out of the DHViP due to well established across Devon, the most the workforce’s existing skills. vulnerable women are being identifi ed at an early stage for the programme, which has THE DHViP led to 80 families being enrolled. FPM training was delivered to It appeared from the research that it is A vital yet challenging component of the often families with two or more identifi ed DHViP is the evaluation of its outcomes. Each vulnerabilities that require and benefi t from health visitor working with a DHViP family intensive health visiting support, but this is 40of the evaluates the work undertaken at the end challenging to provide within the existing of each episode of care, to demonstrate that framework. As such, the DHViP and its design identifi ed outcomes are being met. creates the opportunity for health visitors health visitors The outcomes currently measured to work more fl exibly and creatively when 120 in Devon from the DHViP include breastfeeding meeting a variety of complex needs. data, accidents and hospital admissions To support staff in delivering the DHViP, EPISODES OF CARE and the ages and stages questionnaire. the steering group developed and devised Interestingly, initial fi ndings indicate that a suite of resources, including a guide for the majority of DHViP families have a professionals, a leafl et for parents and a ● Episode 1 Two mental health component and as such, personal handbook for those families who antenatal contacts referrals to mental health support services consented to the DHViP. is shown in the data, which encourages These documents initially supported the ● Episode 2 Weekly appropriate assessment and an opportunity DHViP roll-out in six pilot areas in Devon. contacts for six weeks to build on strengths within the family. This Exeter, north, south and east Devon were after the baby is born is integral to the infant’s wellbeing and selected due to higher levels of need. The highlights the benefi ts of the DHViP. criteria for enrolment were decided based ● Episode 3 Fortnightly But there’s an ongoing need to capture on existing programmes and those raised contacts for two months the outcomes of such essential work. by our own practitioners. They included: Resources and tools to evaluate and measure childhood abuse; women at risk of maternal ● Episode 4 Monthly outcomes are being considered to ensure mental health issues; substance misuse; contacts until the baby the DHViP continues to improve outcomes single or young parents; and parents who is seven months old for children and families in our care. CP had been part of the care system. ● Episode 5 Every other REFERENCES month until the baby is Allen G. (2011) Early intervention: the next steps. See: gov.uk/ 15 months old, which will government/uploads/system/uploads/attachment_data/ fi le/284086/early-intervention-next-steps2.pdf (accessed 10 include a one-year review April 2017). It is often families of development Department of Health. (2009) Healthy child programme: pregnancy and the fi rst fi ve years of life. See: gov.uk/government/ with two or more uploads/system/uploads/attachment_data/fi le/167998/Health_ ● Episode 6 Quarterly Child_Programme.pdf (accessed 10 April 2017). identifi ed vulnerabilities until the child is two Department of Health. (2011) Health visitor implementation plan years and three months, 2011-2015: a call to action. See: gov.uk/government/uploads/ that require and benefi t system/uploads/attachment_data/fi le/213759/dh_124208.pdf when a 2.3 assessment (accessed 10 April 2017). from intensive health is undertaken. NHS England. (2011) Health visiting programme. See: england. nhs.uk/ourwork/qual-clin-lead/hlth-vistg-prog/ (accessed 10 visiting support April 2017).

May 2017 Community Practitioner 39

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The Solihull approach: pros and cons Research that explored the experiences of two professions using the Solihull approach revealed benefi ts and challenges. Eleni Vasilopoulou, Ayesha Afzal, Kirsty Murphy and Clea Thompson explain more.

The Solihull approach (SA) was originally developed to provide of the SA on team relationships and functioning; advantages and health visitors (HVs) with a theoretical framework to conceptualise disadvantages of using the SA; thoughts on training improvements; and manage pre-school children’s sleeping, feeding, toileting and and thoughts on consultation and post-training support. behavioural diffi culties. Since its development, the SA has been Four main themes emerged from the sessions: impact on practice, applied in a range of professional contexts, focusing on practitioners’ challenges when using the SA, training improvements and post- interaction with families and engagement in interagency work. training support. Training has been widened to include a variety of professional Practitioners identifi ed a number of benefi ts of the SA, such as groups, such as nursery staff , family support workers, child and enhanced practitioner refl ection, greater focus on parents’ and adolescent mental health service (CAMHS) staff and social workers children’s feelings and an increased awareness of the family’s (Solihull NHS Primary Care Trust, 2006). readiness in therapy. To fi nd out how the SA becomes conceptualised in diff erent contexts and to evaluate the benefi ts and challenges to diff erent professionals, a team from NHS Fife undertook research into the experiences of HVs and CAMHS staff . It involved a qualitative service evaluation using two focus groups to explore HVs and CAMHS ‘I USED TO BE AN professionals’ views of the SA training and implementation. These INSTANT GIVER OF professions were chosen because of the large number of staff in each discipline trained in the SA, but also by the diff erences in ADVICE, WHEREAS their roles and training that might lead to diff erent experiences of implementing the approach. Three HVs and fi ve CAMHS practitioners NOW I WILL SIT BACK (three clinical associates in applied psychology, one clinical AND I’M A FAR BETTER psychologist, one occupational therapist and one psychotherapist) took part. ACTIVE LISTENER’ The two focus groups, one for each professional group, were conducted in March 2016 in NHS Fife, led by two researchers. The aim was to provide a safe environment in which participants could freely express their views. Facilitator A administered the semi-structured focus group questions while Facilitator B took notes and asked questions for clarifi cation when necessary. The focus group questions developed by the authors were based on previous research on the SA, addressing the following areas: feelings around work; impact

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Participants in the CAMHS and HV groups agreed that the SA off ered a shared language and understanding among professionals. This led to better communication and problem-solving within ‘IT GIVES THAT multidisciplinary teams and when engaging in interagency work.

THEORETICAL TOP CHALLENGES UNDERPINNING TO Alongside the benefi ts, participants identifi ed a few challenges when using the approach in their practice. CAMHS practitioners THINGS THAT WE DO’ discussed challenges around the emotional aspects of sessions, such as managing clients’ emotions during group sessions. Time, stress and workload constraints were the main barriers in implementing the approach mentioned by HVs. Incorporating restorative supervision approaches (Wallbank, 2013) to support both CAMHS and HV practitioners in debriefi ng, refl ecting and managing stressors in their work environment might be benefi cial. CAMHS participants mentioned fi nding it diffi cult to keep a balance between containing the patients’ emotions and delivering These elements are essential in forming and maintaining session content, especially during group work. In addition, three of therapeutic alliances and in establishing positive therapeutic the CAMHS participants who had been involved in delivering SA outcomes (Martin et al, 2000). Practitioners also mentioned that the groups for families and carers considered that containing people’s SA positively infl uenced team relationships and communication by emotions can be diffi cult and can give rise to experiencing their own off ering a shared language among professionals. This is consistent very intense emotions. One said: ‘[Clients] bring to groups some really with previous work in this area (Whitehead and Douglas, 2005). harrowing stories about the children’s background. Things like that can be really very intense to hear.’ IMPROVED PRACTICE Two CAMHS participants felt that the SA concepts were hard Both HVs and CAMHS practitioners mentioned that the SA training to apply within certain high-risk contexts. Although participants infl uenced a more facilitative and collaborative approach in which recognised the importance of containment, they mentioned that, in practitioners were supporting families in making sense of their own some situations, when following child or adult protection guidelines, experiences. Practitioners also stated that the SA highlighted the other procedures need to be taken into consideration, which could importance of exploring families’ needs and their readiness for an appear to confl ict with the SA principles. intervention as part of an in-depth assessment. One HV said the training had changed the approach they took with clients: ‘I used to be an instant giver of advice, whereas now I will sit back and I’m a far better active listener. I think the Solihull model has allowed me to just take that little step back and wait and think about where the mum wants to go or what it is that she is wanting to achieve rather than ‘[CLIENTS] BRING TO me saying, well, I think you should be doing this or I think you need to GROUPS SOME REALLY achieve this. It’s a more collaborative approach.’ SA training has also resulted in enhanced refl ection with both HARROWING STORIES CAMHS and HV practitioners mentioning a more refl ective stance. It has enhanced their capacity to notice reciprocity in the therapeutic ABOUT THE CHILDREN’S relationship and HVs reported that this enabled them to build BACKGROUND’ stronger therapeutic alliances. HVs also said that Solihull training allowed them to pay more attention to parents’ and children’s feelings in the room. Another benefi t for HVs is that the SA has provided a structure and a theoretical model in which their practice could be conceptualised. One said: ‘I think it gives us a model so that we can really relate some of what we are saying to our mums, and it gives us structure to what we are saying. It gives that theoretical underpinning to things that we do.’

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HVs spoke about the recent changes in their roles and the fact that are a number of limitations that need to be borne in mind when they are currently working within a reduced-function environment. considering the results of this study. The research comprises a small When asked how easy it was to apply the SA principles in this setting, sample size, which makes it diffi cult to generalise to other settings. It HVs reported that they fi nd it stressful and challenging. may be helpful to create a questionnaire based on the themes found When asked about the positive aspects of the SA foundation in this research, as well as those from previous studies, as this may training, practitioners in both groups mentioned enjoying the increase the ability to generalise from the fi ndings. information on early years, particularly brain development and However, size notwithstanding, the study off ers some preliminary attachment. The negative aspects of training included the pace and evidence on the impact of the Solihull approach on clinical practice delivery. For example, professionals stated that the training included and can help improve future training and post-training support. CP a lot of input, which they found diffi cult to consolidate. Practitioners also said that at times the training felt ‘a bit dry’ and wondered whether changes in training delivery and presentation could make it more engaging in the future. For example, one CAMHS KEY participant wondered whether it would have been useful to include POINTS experiential learning in the SA training. HVs also wondered whether ● A qualitative service evaluation set out to understand the introducing ice-breaking activities would have made the training experiences of practitioners using the Solihull approach more engaging. ● Two focus groups, including four CAMHS staff and three health visitors, were included in the study GAPS DISCOVERED ● Themes that emerged included impact on practice, The lack of additional sessions to help implement the approach challenges when using the approach, training in practice was the main identifi ed gap in post-training support. improvements and post-training support This has been a recurrent theme in SA evaluations (Basset, 2015). ● Implications for future training development and clinical Participants in both focus groups agreed that post-training support practice were discussed. was important and discussed ways in which this could be achieved. Both CAMHS professionals and HVs agreed that it would be benefi cial to set some time aside in order to support each other and help with the implementation of the model. HVs and CAMHS professionals ELENI VASILOPOULOU identifi ed a number of challenges when using the SA. Clinical associate in applied psychology, NHS Fife CAMHS participants discussed that it might be diffi cult to obtain SA group supervision with a wide professional group because AYESHA AFZAL practitioners may have diff erent views of supervision. For HVs, the Specialty trainee 6, child and adolescent mental health services, diffi culties in doing this were due to time and workload constraints. NHS Lothian As one HV remarked: ‘When I fi rst did the training we had very good consultation, but it’s diffi cult to keep it all going. As soon as work KIRSTY MURPHY demands increase, things like supervision or consultation tend to be the Clinical associate in applied psychology, NHS Fife fi rst thing to go.’ HVs discussed that it might be benefi cial to develop more robust DR CLEA THOMPSON online or electronic resources in order to help practitioners update Clinical psychologist, NHS Fife their SA knowledge and skills. They felt this would support the implementation of the approach and provide a time-effi cient REFERENCES alternative to group sessions. Basset A. (2015) Solihull approach trainers practice session toolkit. (Unpublished). A recent development of the SA has been the implementation of Martin DJ, Garske JP, Davis MK. (2000) Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review. Journal of Consulting and Clinical Psychology 68(3): theory-to-practice sessions to support practitioners in embedding 438-50. the approach (Basset, 2015). Evaluating these sessions would be Solihull NHS Primary Care Trust. (2006) Solihull approach trainers’ pack: for training care benefi cial to see if they meet practitioners’ post-training needs. professionals working with infants, children and young people. Jill Rogers Associates: Cambridge. Wallbank S. (2013) Maintaining professional resilience through group restorative supervision. The qualitative service evaluation provided an in-depth Community Practitioner 86(8): 26-8. understanding of the experiences of HVs and CAHMS staff in being Whitehead RE, Douglas H. (2005) Health visitors’ experiences of using the Solihull approach. trained in the SA and using it in their practice. However, there Community Practitioner 78(1): 20-3.

To view the full version of this research article, go to bit.ly/CP_research_vasilopoulou

42 Community Practitioner May 2017

40-42 PP_Solihull.indd 42 27/04/2017 13:03 RESEARCH The power of volunteers A volunteer programme that gives support to vulnerable families demonstrated that a small investment in training and support can bring about enormous change. Pauline Lee, Sarah Cook and Catherine Mee explain more.

Being a new parent can be tough for anyone and even more so to develop a partnership project with HOST, in which HOST when there are mental health needs. When a 2012 review of the volunteers would be given purpose-designed training on integrated parent-infant mental health (PIMH) care pathway in fostering sensitive and responsive parent-infant relationships. Tameside and Glossop indicated that more support was required for parents at risk because of mild to moderate mental health VOLUNTEERS needs (Lee and Mee, 2015), a partnership approach was adopted. Home-Start recruits, trains and supports volunteers, who are Although there was professional support available for these parents themselves, to provide weekly home visiting support parents, it was limited and some families are reluctant to seek to families who have a wide range of needs, and at least one help because of a perceived stigma. child under the age of fi ve. In 2014, HOST appointed a new PIMH We decided we needed low-level individual support for coordinator, funded by the clinical commissioning group, to parents to help them along the fi ve ways to wellbeing (New work in close partnership with EAS. Through this partnership, Economic Foundation, 2008), to promote the development of the EAS has been able to off er regular individual and group positive parent-infant relationships, and to engage families with supervision, specialist training and development opportunities local children’s centres and other community provisions. This to the PIMH coordinator and the Home-Start coordinators. type of proactive parental engagement and support would The PIMH coordinator acts as a conduit. She benefi ts from mean that specialist resources were used more appropriately being a part of the EAS team and brings the knowledge and while promoting long-term community support networks. learning from this into the wider Home-Start team. Equally, the So Home-Start Oldham, Stockport and Tameside (HOST), the EAS team can understand the full potential of using volunteers Tameside and Glossop early attachment service (EAS) and to support the development of the parent-infant relationship. Tameside health visiting service developed enhanced training The EAS has gained confi dence in the support that can be for volunteers. off ered by non-clinical staff , thanks to being involved in the high Volunteers’ contributions are vital, and not just because they quality of training and supervision given to volunteers. off er a way of increasing manpower for very little cost. The The existing Home-Start training gives volunteers a 10-week support given by volunteers is unlikely to be achieved by an preparation course before being matched to a family. Once equivalent number of paid workers, simply because the nature matched, the volunteer will visit the family for two to three hours of the relationship with the family is peer-to-peer, rather than a week and off er a wide range of practical help and emotional professional to family. This brings huge potential benefi ts in support. This is overseen by Home-Start coordinators, who terms of trust, the ability to engage families who are less willing review the support given to each family to ensure that existing to be involved with statutory services, and the possibility of needs, as well as any new ones, are being met. developing a relationship with the family, which can make it The enhanced PIMH training was provided in addition to more likely that positive change can occur in the future (Institute the preparation course over four days. It draws on theories for Voluntary Action Research, 2016). from attachment, infant development, psychoanalysis and In Tameside and Glossop, there is a comprehensive and cost- neuroscience. It focuses on pregnancy through to six months of eff ective PIMH provision of services led by EAS. The new support age from the varying perspectives of the parent, the infant and need that had been identifi ed seemed like an ideal opportunity the parent-infant relationship. It covers the importance of early

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brain development, perinatal mental health, refl ective functioning, the Solihull approach, newborn behavioural observation, emotional development of the baby, risks in relationships and the concept of ‘ghosts in the nursery’ (Fraiberg et al, 1975). The training is delivered through an experiential approach where information is shared and volunteers are encouraged to share their thoughts, feelings and experiences. The arena of PIMH is particularly volunteers have been emotive and inevitably stirs up thoughts in all of us about how we trained in PIMH were as infants and children, how we were parented and how we 52... of these parent our own children. The training is given by three professionals – the PIMH coordinator from HOST, a health visitor and an EAS specialist – to make the most of their diverse knowledge. Many of the concepts that are discussed are experienced live during the training, such as mirroring of emotions and containment. 20reached the point The training translates theory into practice through the use of where they had group exercises, bringing in various resources – such as keepsake been matched with a books and dream catchers – and encouraging volunteers to think family and completed about how these might be used to support the parent-infant the evaluation relationship. Volunteers give feedback at the end of each training questionnaire and feedback interview session, verbally and via Post-it notes, to allow facilitators to gauge how the session was experienced and what needs to be adapted or considered in the following session.

TABLE 1: COMPARISON OF PARENTS’ RATINGS OF THE TWO GROUPS OF VOLUNTEERS

MEAN SCORE† P* ENHANCED TRAINING NORMAL TRAINING

1 They helped me with my own problems 3.00 2.46 <.05

2 They helped me build a relationship with my baby 2.85 1.96 <.01 3 They helped me understand baby states 2.35 1.23 <.01 They helped me understand the importance of 4 2.60 1.35 <.01 brain development 5 They helped me with soothing my crying baby 2.75 1.59 <.01 6 They helped me with feeding my baby 2.70 1.65 <.01 7 They helped me with my child’s sleep 2.70 1.50 <.01 8 They helped me with coping when things were diffi cult 2.90 2.60 <.05 9 They helped me recognise baby stress signs 2.25 1.08 <.01 They helped me realise how important my relationship is 10 2.70 1.46 <.01 to the development of my baby’s mind 11 I feel more confi dent about my ability to care for my baby 3.00 2.01 <.01 I valued the fact that the volunteers were parents 12 3.00 2.89 Not sig themselves They helped me realise how much my baby has a 13 2.65 1.39 <.01 thinking mind 14 I felt the service was unable to meet my needs 1.00 1.00 Not sig

†Scoring on the questionnaire: Certainly true = 3, Partly true = 2, Not true = 1, Don’t know = 0 *Mann-Whitney U test

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SUPPORT have not engaged with health visitors and other agencies but The families are off ered a tailored package of intervention have accepted the befriending approach off ered by Home-Start dependent on their individual needs. This could involve supporting volunteers. This can support families to engage with services when the development of the parent-infant relationship through refl ective they are ready. Volunteer feedback reveals that, while they fi nd it functioning of the parents, increased intuition with their baby’s benefi cial and rewarding to help families, the work can also have an communication cues and helping parents think about their babies’ emotional impact, which requires support to be available. thought processes. The PIMH coordinator matches a PIMH-trained Best of all, the impact on parents’ experiences has been even volunteer with the family to follow an action plan that has been bigger than we could have hoped. We are optimistic that the agreed by the family, volunteer and coordinator. relatively modest investment in time and expertise will bring real To ascertain the diff erence that the enhanced training made, we benefi ts to them, their children and the society in which they live. CP devised a simple questionnaire that all families, regardless of whether or not they had a PIMH-trained volunteer, would complete at their six-month review and at the end of their Home-Start support. All KEY families with a child of two years or under, or expecting a baby, were POINTS asked to complete the questionnaire. At the end of the enhanced training, volunteers were also asked to complete an evaluation. ● Tameside and Glossop early attachment service aims to At the time of writing, a total of 52 volunteers have been trained in meet the needs of all parents, from those with a high level PIMH. Of these, 20 reached the point where they had been matched of need through to a universal provision with a family and completed the evaluation questionnaire and the ● Some families are nonetheless isolated and may also feedback interview. The comparison group comprised 76 volunteers be reluctant to seek professional help because of a who were yet to receive the PIMH training, but had completed the perceived stigma evaluation questionnaire with a family. ● Volunteers are often more able to engage families who The knowledge and confi dence parents acquired under the two are less willing to be involved with statutory services training regimes diff ered dramatically, particularly in issues around ● A partnership project with Home-Start and health the relationships with their babies (see table 1). It was clear that the visiting was developed, in which volunteers were given parents receiving a service from the specially trained volunteers felt a purpose-designed training around the fostering of more confi dent in building a good relationship with their infant. sensitive and responsive parent-infant relationships Focus groups with volunteers, who were using their new ● Results showed that this short training course had knowledge in their work with families, revealed they had found the a remarkable impact on parents’ knowledge and preparation course helpful, but the PIMH course had given them confi dence in building relationships with their infants. much more in-depth knowledge. They found the course to be very emotional at times, but it encouraged them to think diff erently about parent-infant relationships. PAULINE LEE Consultant clinical psychologist, clinical lead, Tameside and Glossop CONFIDENCE Early Attachment Service, Pennine Care NHS Foundation Trust The volunteers described how it had informed their work. One said: ‘As I was doing the course, I was matched with a family where Mum had SARAH COOK no maternal instincts. She ignored the baby. The course helped me to Chief executive, Home-Start Oldham, Stockport and Tameside help her. I went back to the child to help her to see what the child needed. When the child does this, do that. She learned to react to the child. I CATHERINE MEE wouldn’t have done what I did without the course; it gave me confi dence.’ Clinical pathway lead, Children’s Universal and Universal Plus Another volunteer said: ‘The family I am with have a four-year-old services (Tameside Community Services), Tameside and Glossop and a one-year-old. Mum has postnatal depression. I started the PIMH Integrated Care NHS Foundation Trust course and began to observe more and look at what the baby is telling us. I haven’t been saying what to do, but just showing. I have noticed that REFERENCES the baby is now more independent, Mum is including the baby more and Fraiberg S, Adelson E, Shapiro V. (1975) Ghosts in the nursery: a psychoanalytic approach to there is more interaction.’ the problems of impaired infant-mother relationships. Journal of the American Academy of Child Psychiatry 14: 387-421. The evaluation demonstrated that a fairly short, targeted training Institute For Voluntary Action Research. (2016) Volunteering and early childhood outcomes: a review course for volunteers could have a remarkable impact. For health of the evidence. Big Lottery Fund: London. visitors, there have been wide-ranging benefi ts. Networking and Lee P, Mee C. (2015) The Tameside and Glossop early attachment service: meeting the emotional understanding of one another’s roles and available services has needs of parents and their babies. Community Practitioner 88(8): 31-5. New Economic Foundation. (2008) Foresight mental capital and wellbeing project. Government improved, and this has helped support families. Some families Offi ce for Science: London.

To view the full version of this research article, go to bit.ly/CP_research_lee

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As public health services oint working between health and baby cues. Fathers are invited to the visiting and talking therapy seventh session to discuss their roles and remain under threat, services at Somerset Partnership health needs. A follow-up session is held NHS Foundation Trust has been for each group of mothers so they can the case for a joined- delivering positive results at maintain their peer support. Following each Jperinatal mental health groups for session, the health visitor and PWP debrief up approach has never mothers, fathers and their babies. and supervise each other. Health visitors been stronger. Jenny The aims of the joint working are for and PWPs developed the session contents Thompson describes health visitors to learn assertiveness and in consultation with mothers, and a toolkit therapeutic intervention skills from their containing all the related material is available a collaborative project talking therapy psychological wellbeing to staff working with mothers. in Somerset that’s practitioner (PWP) colleagues, and for PWPs to learn about parenting and child BACKGROUND improving perinatal development from the health visitors. In 2015 the updated perinatal mental For the parents attending the Horizon health pathway directed health visitors mental health outcomes. perinatal mental health groups, the to refer mothers with mild to moderate goals are to understand perinatal mental perinatal mental illness to their GPs and health, build strategies to deal with their talking therapy services. But health visitors illness, develop peer support, learn about seemed reluctant to make referrals to talking healthy lifestyles and promote their child’s therapies – they reported that some mothers emotional wellbeing. An expected outcome didn’t want consultations over the phone. So is that mothers’ mood levels will improve, the task was to identify how to improve joint evidenced by scores on the Patient Health working between health visiting and talking Questionnaire 9 (PHQ9) and generalised therapies to ensure mothers were receiving anxiety disorder (GAD) screening tools. the best from the perinatal interventions The Horizon groups consist of seven off ered by both services. three-hour weekly sessions, run by a health In Somerset, health visitors had been visitor and a PWP. Each session has a theme, running a group called ‘Mums’ time’ for such as assertiveness or learning to live with mothers with perinatal mental health perinatal mental health issues. The groups problems. This had some good outcomes, are off ered to a mother during the antenatal including mothers developing peer support period until her baby is a year old. They run and fathers having a better understanding of as a rolling programme, so mothers can perinatal mental health. attend sessions when they’re able. But it also highlighted that health visitors Mothers can bring babies under six would benefi t from better knowledge months to support breastfeeding and and skills by working therapeutically with promote understanding of attachment mothers. Health visitors reported they

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felt out of their depth on perinatal mental ●Health visitors have learned assertiveness it.’ And the babies’ presence allowed the health and that they would benefi t from skills from PWPs, and PWPs learned about health visitor and PWP to discuss bonding supervision by mental health colleagues. parenting and child development from and attachment, and to demonstrate simple They also said that when they liaised with health visitors interaction in play, while mothers could mental health services, particularly on ●Mothers’ self-esteem and self-worth has maintain breastfeeding. children’s safety and wellbeing, they found improved, making them feel safe and Another positive outcome is that mothers their mental health colleagues had little supported. They developed self-care with anxiety reported feeling calmer after understanding about the health visitor role, strategies to manage their condition attending the group. One said she was children’s development and the impact a ●PHQ9 and GAD scores reduced after two relieved to hear other mothers express mother’s illness could have on her children. to three sessions feelings that she had felt ashamed of, such Out of this came the idea to run the joint ●Mothers and fathers understood what as resenting her baby for making her feel perinatal mental health groups. These perinatal mental health is so anxious. Other mothers said they had groups would build on the successful ●Fathers learned about their role in the laughed for the fi rst time and had fun. outcomes of the ‘Mums’ time’ programme, family (anxious mothers had inadvertently while attempting to improve joint working restricted the fathers’ input into child care LEARNING POINTS between services. and parenting) Mothers who attended the original Horizon group formed a trusting relationship with IMPLEMENTATION the health visitor, but a few then stopped So the roll-out of Horizon groups began, interacting with their mental health worker. run jointly by a health visitor and a PWP. In some cases the mother contacted Four planning sessions took place, including This has been an the health visitor when feeling suicidal, a shared training session with the health extremely successful potentially leaving herself at risk and visitors and PWPs who would be running the causing stress to the health visitor. groups, initially in two areas of Somerset. joint service way of This was a key reason for starting the joint Just four mothers were invited to those working, which has working. The talking therapy staff upskilled fi rst groups, allowing the health visitors and the health visitors to feel more confi dent in PWPs to familiarise themselves with the been shown to achieve talking to mothers about suicide, while the programme and to identify what worked fantastic outcomes Horizon sessions included time to discuss and what needed changing. The lack of self-care and how mothers should ask for crèche funding led to the practical decision the right help and work with their mental to let babies attend, though mothers ●Mothers and fathers increased their health worker. were encouraged to fi nd childcare for support systems within the community In addition, when mothers discuss babies over six months. The fi rst groups ●Mothers understood baby cues, got thoughts of harming their children, the also experimented with rolling sessions, to know their babies and began to health visitor and PWP have to assess the welcoming new mothers into established enjoy parenting. situation and consider increased mental groups, and a session for fathers. health support and/or the safety of The trials were a success and Horizon The initiative has also challenged past the child. sessions are now established in four areas. concerns about running groups – for They also discuss confi dentiality and A monthly steering group receives feedback example, mothers could join at any stage their safeguarding responsibility at the from each area and evaluates outcomes and rather than be forced to attend every session start of each session. Health visitors inform feedback in order to adapt the programme. to stay with a group, which worked well safeguarding nurses when they rerun PHQ9 and GAD scores are collated to for mothers who at times felt low in mood groups and ask for extra supervision. evaluate service delivery. and energy. Welcoming new mothers and Overall, this has been an extremely returning mothers at the start of sessions successful joint service way of working, OUTCOMES allowed them to feel accepted. One said: ‘If which has been shown to achieve fantastic All the objectives of the joint working I’m having a bad week I know I can come back outcomes for women and their families. CP and running of Horizon groups have another week and that’s okay.’ been achieved with excellent results. Health visitors and PWPs initially found ● Jenny Thompson is manager of These include: it harder to run sessions with babies. But as public health nursing teams and ●Health visitors and PWPs understand one PWP acknowledged: ‘Mothers multitask lead on perinatal and infant mental each other’s roles, refer mothers between all the time. It was me who found the babies health, Somerset Partnership NHS

ISTOCK services, and benefi t from supervision more distracting, so I learned to deal with Foundation Trust.

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Winning the VACCINE RACE Medical research and science writer ’ve been interested in vaccines Meredith Wadman Murphy, 2007). In 2016, there were since childhood – my father was an 69 cases (Centers for Disease Control obstetrician-gynaecologist and my explains her passion and Prevention, 2017). The last measles mother, before she had children, was a for vaccines and how a death in the US was likely in 2015 (Liko public health nurse. They talked about et al, 2015). Ithe importance of vaccines, and I lived in particular story gave her And yet some people are fearful of an environment that very much supported unexpected inspiration vaccines. I think this resistance has taken vaccination. Also, I was born in 1960, so the hold because vaccines have done so well damage done by diseases like measles and to write a book. at eliminating the diseases they target. We polio was fresh in the public mind. don’t see children in leg braces from polio, As a medical student in the 1980s, I and we seldom, in wealthy countries, lose completed electives on paediatric wards toddlers to measles or pertussis anymore. and in public health clinics in west Africa, And complacency sets in, and parents South Africa and Sarawak, on the island of don’t realise that it is precisely because we Borneo, where I travelled by riverboat to continue to vaccinate that we don’t see jungle longhouses. these diseases today. In all these places, the agony and death Of course, there is some risk: no caused by vaccine-preventable diseases medicine or vaccine is absolutely without was abundantly, heartbreakingly clear, it. What’s more, with vaccines that we are particularly in babies and children. putting into young, otherwise healthy children, the safety bar is especially THE VALUE OF VACCINES high. Some side eff ects are common, like If we didn’t have vaccines, the world redness or soreness at the injection site. would look very diff erent today. Along But it’s hard to detect rare problems until with antibiotics and clean drinking water, a vaccine goes into tens or hundreds of I think vaccines are the great public health thousands of people. victory of the 20th century, at least for richer countries. You need only look INSPIRED TO WRITE at morbidity and mortality rates Until the late 1960s, tens of thousands for infectious diseases in the last of children suff ered crippling birth century and compare defects if their mothers had them with today’s to be been exposed to rubella persuaded of this. while pregnant; there Here’s one example: in was no vaccine and the US in 1958, there were little understanding 763,094 cases of measles of how the disease and 552 deaths (Roush and devastated fetuses.

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But in June 1962, a young biologist named Hayfl ick and Plotkin, I knew I had to try to Leonard Hayfl ick from Philadelphia, US, make a book of it. used tissue extracted from an aborted KEY STATISTICS I’ll be happy if the book lifts the curtain fetus from Sweden to produce safe, clean a bit on the process of science, the cells that allowed the creation of vaccines importance of vaccines and the ethical against rubella and other common shortcuts that were taken 50 and 60 years childhood diseases. Two years later, in the 763,094 ago in human trials (testing on infants, midst of a devastating German measles prisoners, orphans, and the intellectually epidemic, his colleague Stanley Plotkin cases of measles in the US in 1958 disabled, which was common in the era) developed the vaccine that would one – so that they don’t happen again. CP day wipe out home-grown rubella in the western hemisphere. ● The Vaccine Race by Meredith Wadman That vaccine has protected more than and 552 deaths is available now. 150 million people in the US alone, the vast majority of them pre-school children. The compared to only REFERENCES new cells and the method of making them Centers for Disease Control and Prevention. (2017) Measles cases and outbreaks. See: cdc.gov/measles/cases-outbreaks. also led to vaccines that have protected html (accessed 20 April 2017). billions of people around the world from Liko J, Guzman-Cottrill JA, Cieslak PR. (2015) Notes from the 69 fi eld: subacute sclerosing panencephalitis death – Oregon, polio, rabies, chicken pox, measles, hepatitis cases of measles in the US in 2016 2015. See: ncbi.nlm.nih.gov/pubmed/26765654 (accessed A, shingles and adenovirus. 20 April 2017). The scientists’ story and the political Roush SW, Murphy TV. (2007) Historical comparisons of and morbidity and mortality for vaccine-preventable diseases in roadblocks that almost stopped them really reported the United States. Journal of the American Medical Association resonated with me. After I fi rst interviewed 1death 298(18): 2155-63.



 


   

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May 2017 Community Practitioner 49

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Upcoming courses, training and events relevant to practice… countries. A one-day national practical steps to prevent them, SUN AWARENESS WEEK conference in London is also set presented in an engaging way. 8-14 May to be included. W: bit.ly/CAPT_CSW2017 Raising awareness across the UK #HVweek about the risks of sun exposure. Free posters and leafl ets can #SN WEEK PND AWARENESS WEEK 10-14 July be ordered from the British 4-11 September Unite-CPHVA brings you this Association of Dermatologists. Join the PANDAS Foundation week-long event celebrating W: bit.ly/BAD_sun_awareness to raise awareness around pre- the work of school nurses across and postnatal depression. the UK. More details on how CHIEF NURSING OFFICER Details TBC to get involved will follow in FOR WALES CONFERENCE Community Practitioner and on 10 May TE-CPHVA ANNU social media. UNITE-CPHVA ANNUAL Annual showcase conference, #SNweek PROPROFESSIONAL with topics including leadership, CCONFERENCE 2017 quality, workforce development 17-18 October SCHOOL NURSES and patient/public involvement. Join your colleagues and peersrss INTERNATIONAL 2017 Location: Cardiff City Stadium in community practice to CONFERENCE network, share best practice 24-28 July WORLD NO TOBACCO DAY and discuss ideas at this annual The theme for this year’s event 31 May two-day event. is ‘School nurses interacting Annual event to highlight the Location: Motorpoint Arena,na, within the public health model health and additional risks CardiffCa to promote the health of associated with tobacco use. W: bit.ly/CPHVA_call_for_papersbit.ly/CPHVA_call_for_pa children – globally’. This year’s theme is ‘Tobacco Location: San Francisco, US – a threat to development’. W: bit.ly/SNI_2017 W: bit.ly/WHO_no_tobacco ADVERTISE WITH US #HVWEEK If you would like to CHILD SAFETY WEEK 21-25 August advertise here, contact 5-11 June Building on the resounding senior sales executive Alex The Child Accident Prevention success of last year’s UK-wide Edwards on 020 7324 2735 Trust is asking professionals event, #HVweek returns with or email alex.edwards@ to share their experience and various events taking place in redactive.co.uk knowledge – not just about your respective regions and the horrors of accidents, but

50 Community Practitioner May 2017

0 ia ats.indd 0 27/04/2017 13:06 Courses COMMUNITY TO ADVERTISE PRACTITIONER www.communitypractitioner.com | www.unitetheunion.org/cphva CONTACT: Alex Edwards dl 020 7324 2735 e [email protected]

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Our including study days with expert 25 Bickerton Road, London N19 5JT curriculum is taught in more than 45 speakers, trainer-led massage stroke 30th September and 1st October 2017 countries and has been developed and refresher sessions and a biennial Peter Walker a physical therapist yoga teacher and author gives this unique course with refined over 30 years through research, international conference over forty years experience in teaching teachers and working directly with mothers reflective practice and practical OAccess to relevant articles, and babies. Techniques based upon the stages of the baby’s physical and emotional experience. This has resulted in a widely information and the latest research development. Supported by neuroscientifi c research this forms the basis of a high endorsed and implemented parenting on our website quality inexpensive teacher training program. programme. OA regular newsletter. Peter is credited with the free teaching of baby massage in NHS centers throughout the Our highly acclaimed comprehensive Our training courses are run regularly at UK. Peter personally teaches all his teachers and his teacher training programs remain training comprises: centres nationwide and are facilitated unfranchised. Certifi cate accepted in childcare centres and high quality health studios. by experienced IAIM Trainers. OA four-day training course including Childhood lasts a lifetime and starting from confi nement the fi rst two years is known supervised practical teaching of a Find us on Facebook - IAIM UK Chapter to be the most signifi cant in all aspects of a child’s development. (1001 Critical Days) parent/baby massage class Full set of illustrated course notes ‘step by step’ from birth to standing supplied. OA take home written assignment For further details please visit OFurther practical teaching and reading. www.iaim.org.uk. In-house THIS COURSE INCLUDES trainings are available on request. A HOLDING REASSURANCE PROGRAM and the ‘enteric nervous system’. By training with our highly respected FROM THE FIRST FEW DAYS Introducing good reciprocity organisation you will join a worldwide IAIM (UK) Chapter FOLLOWING BIRTH between the mother and her baby. network of instructors offering a 0208 989 9597 Can be shown to expectant supportive environment to teach [email protected] mothers during late pregnancy DEVELOPMENTAL BABY MASSAGE life-long parenting and relaxation skills. www.iaim.org.uk and/or during the early days and FROM 8-10 WEEKS TO STANDING weeks following childbirth. Further techniques using massage and A program of gentle massage and movement to ensure the fl exibility movement to relieve any trauma of all their body’s major joints before resulting from fetal distress during the child strengthens them by lifting confi nement, birth and /or early days. and carrying a rapidly increasing To assist in the release of physiological bodyweight against the force of gravity, fl exion and thereby encourage a sitting, crawling, standing and walking. deeper breathing rhythm, more relaxed To encourage good posture sitting, tummy and a much happier baby. standing & walking and maintain good Touch-Learn International’s Birth, babies, primal knowledge reciprocity between mother and child. Baby Massage Teacher Training Free bi-monthly quality newsletter • Post course support. www.babymassageteachertraining.com Venues across the UK, plus in-house OAll mechanisms identifi ed in current www.thebabieswebsite.com option. A fi ve-day, comprehensive research to support parent-infant Email: [email protected] • Tel: 01752 939767 baby massage teacher course for relationships health professionals and parenting OUnderpinning theory based on practitioners provided by Touch-Learn current research International, the exemplary training O Practical teaching in the fi eld company. This highly acclaimed  Read by more programme is accredited by The Royal ORelevant anatomy and physiology COMMUNITY health visitors College of Midwives and the University OQuality supporting materials and than any other of Wolverhampton. text books PRACTITIONER journal This quality training programme OSummative assessment includes simple massage techniques, OFree, informative biannual From a 16,500 circulation the journal reaches: coupled with an in-depth knowledge newsletter to practise safely, ethically and 80% O Tutorial and on-going support · of the UK’s health visitors professionally so practitioners feel  confi dent to teach parents in a variety · 75% of all UK school nurses of settings. Trainers are all experienced Other courses from Touch-Learn practitioners with professional/HE OMassage for Babies with Special Community Practitioner is an ideal platform teaching qualifi cations. Needs to promote your product, service or O Baby Yoga Teacher Included within the course: O Baby Signing Teacher vacancy as it reaches highly skilled OStrategies to empower parents OBaby Wearing Advisor professionals who constantly refer to the title for information and advice. For further details of in-house training and UK dates please ring or visit www.touchlearn.co.uk CONTACT Touch-Learn International Ltd Tel: 01889 566222 [email protected] If you want to reach this valuable audience, please contact: www.touchlearn.co.uk [email protected] or call 020 7324 2735

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