Norfolk: The integration of Parent-Infant Relationship and Perinatal Mental Health services

In Norfolk, the Parent-Infant Relationship service (PAIRS) and Perinatal Mental Health (PMH) service had a well-established offering before receiving Family Hubs and Start for Life programme funding. However, there was limited collaboration between the services and referrals to PAIRS had declined after COVID-19. Locally collected data also showed low awareness and uptake of PMH services among fathers. To address these issues, the team recognised the need to better integrate PAIRS and PMH pathways in Family Hubs to increase referrals. They aimed to guide families to the appropriate service for their needs, regardless of where they first made contact, using a ‘no wrong door’ approach to prevent families from falling through the gaps. Norfolk also recognised the need to increase the workforce capacity to accommodate the expected increase in service use.

The team focused their intervention around three core concepts to increase referrals into PAIRS and PMH pathways:

1. Achieving greater integration
2. Increasing staff capacity to enable the enhancement of services
3. Engagement with fathers

1. Set-up meetings for purposeful communication between services: Bi-weekly meetings between the PAIRS and Early Childhood and Family Service (ECFS) teams ensure their services are joined-up. This enables discussion of the needs of specific families and decision making on whether they require ‘stepping up’ to PAIRS or ‘stepping down’ to ECFS. Consistent communication ensures seamless transitions and appropriate support for families.
2. Pool resources with other Family Hubs and Start for Life services to deliver integrated interventions: For instance, Home-Start Norfolk, a voluntary organisation, has been commissioned to provide peer support across multiple Start for Life areas. The team also used Family Hubs and Start for Life programme funding to hire dedicated participation officers who identify communities least likely to engage with Family Hubs and recruit potential peer support workers from within those communities. One participation officer successfully built positive relationships with the traveller community in Great Yarmouth and recruited peer support volunteers from that community to ensure long-term engagement. Furthermore, the team pooled funding to establish and train a dedicated intervention delivery Team within the local ECFS. This integrated team works in Family Hubs to provide evidence-based interventions and to support families across various pathways. The interventions include Triple P Baby and Video Interactive Guidance to improve parent-infant attachment.
3. Embed established pathways into the Family Hubs model: In Norfolk, NHS Talking Therapies have been successfully embedded in the Family Hubs model. Services are now co-located and delivered within Family Hubs to encourage co-working, knowledge sharing and easier transition for families requiring varying levels of support.
4. Upskill universal pathway staff members: Funded training for universal pathway staff is offered so that more staff are able to provide evidence-based interventions. This has increased the number of people in the workforce who can identify and support families. The team also produced a father inclusive practice training package which has been rolled out to 95 individuals. All mandated health visiting staff members and ECFS staff members are trained to use assessment tools, such as the Mothers Object Relations Scales, to screen and identify families with relationship or mental health needs which could be met through specific PAIRS and PMH services. Staff members are then able to refer families onwards to the most appropriate intervention through newly developed arrangements.
5. Increase awareness of all Start for Life pathways amongst staff members: To further improve integration, Norfolk disseminates foundational core training to staff and the wider system to increase understanding of all pathways under the Start for Life offer within the area. Specific PAIRS and PMH training has also been developed and rolled out across the Family Hubs workforce to increase awareness of the local services available and how families may benefit from accessing them. Through these interventions, the team aimed to improve the ability of staff members to signpost families to appropriate interventions and encourage staff to identify opportunities for co-production.
6. Increase staff capacity: Norfolk also used Family Hubs and Start for Life programme funding to increase capacity within their local PAIRS to ensure sustainability for the entire Start for Life period. Additional clinical capacity was added (including a parent-infant psychotherapist, psychologists, parent infant practitioners and an administrator) to enhance evidence-based interventions, including Circle of Security and Parent-Infant Psychotherapy.
7. Implement a flexible recruitment strategy: To overcome some of the challenges associated with workforce capacity in the mandated health visiting offer, the team in Norfolk were successful with their bid to become a Workforce Pilot area. Norfolk received grant funding from the Department of Health and Social Care to pilot innovative ways of improving the skills mix of staff members and supporting the recruitment and development of staff. Norfolk had difficulties recruiting psychological wellbeing practitioners into the Perinatal Talking Therapies pathway. To address this issue, psychological wellbeing practitioners were offered secondments to become perinatal specialists. To ensure the capacity of the workforce was not compromised, these roles were backfilled and supported by additional alternative digital therapy capacity. The secondments also led to the cross-fertilisation of ideas and shared learning between services. Norfolk also focussed on recruiting for more junior positions since these vacancies were easier to fill. Whilst this did result in a short-term skills gap, newly recruited junior staff were supported with training using Family Hubs and Start for Life programme funding, with the aim of achieving workforce sustainability in the long term.
8. Leverage community partnerships to deliver services for fathers: The team invested £135,000 in community and voluntary sector grassroots organisations to offer place-based social activities for fathers under the PAIRS and PMH pathways. This was facilitated by a partner organisation that invited local services to submit bids for grants. A multi-agency panel, which included fathers from Norfolk’s Parent and Carer panel, assessed each bid and decided on which organisations received funding.
9. Plug service gaps: The team recognised that there was a limited offer for families with mild-moderate mental health needs following pregnancy loss. Consequently, Time Norfolk (a local charity and a member of the Baby Loss Awareness Alliance) was commissioned to deliver an enhanced counselling offer that extended to co-parents, fathers and siblings.

Since undertaking this work, Norfolk reports an increase in referrals to PAIRS and PMH services. For example, in 2023/24 referrals to PMH services rose by 33% from 2022/23, with a notable increase in the number of fathers seeking support. Referrals for fathers/co-parents have increased by 60%, compared to a 28% increase in referrals for mothers. This is further supported by the father inclusive practice training that 95 individuals have received so far. Attendees report a 45% increase in knowledge and confidence pre and post training and noted a tangible change to professional practice. Additionally, the integration of services with the Family Hubs model has streamlined the referral process and enhanced informal consultation support among staff, leading to improved integration across early years services.

The incorporation of NHS Talking Therapies pathways within Family Hubs has enhanced staff members’ skills through exposure to experienced specialist practitioners. The PMH pathway within NHS Talking Therapies has been particularly successful with 1376 people (women and fathers/coparents) completing treatment in 2023/24. On average, 50% of individuals participating in the core Talking Therapies programme in the UK achieve recovery, with a reliable improvement rate (positive change in the families’ condition, according to measures observed pre and post intervention) of 60%. In Norfolk, the results are even more impressive. Locally collected data (2023/24) indicates that 58% of individuals accessing the PMH pathway achieve recovery and a 73% reliable improvement on their scores. However, the Norfolk team has noted that due to the long-term nature of the interventions, it may take some time to evidence other desired positive outcomes, such as reductions in the numbers of families in contact with social care teams or improvements to children and young peoples’ mental health.

The PAIRS and PMH teams in Norfolk have learnt that integrating pathways requires a conscious effort to develop and maintain. They achieved this by mixing staff from different services through the Family Hubs, encouraging training and secondments and committing to frequent cross-service communication. As a result, the workforce gained a better understanding of the wider support available, learned from shared experiences and increased referrals to prevent families from falling through the gaps.

This case study has been produced by the Start for Life Unit within the Department of Health and Social Care, in partnership with RSM and Norfolk County Council. By sharing promising examples of delivery, we hope to facilitate connections between LAs across the country and support LAs in their delivery of Start for Life services. For further information please contact familyhubs.startforlife@dhsc.gov.uk

The data included in these case studies is self-reported by Local Authorities and has not been quality assured by the Department of Health and Social Care. The views expressed are those of the authors and not necessarily those of the Department.