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C4EO theme: Early Intervention

Targeted Parenting Programme for Families with Multiple Difficulties, Luton

Themes this local practice example relates to:

  • Early Years
  • Families, Parents and Carers
  • General resources
  • Local area early intervention strategies

Priorities this local practice example relates to:

    Basic details

    Organisation submitting example

    Luton Borough Council/NHS Luton

    Local authority/local area:

    Luton Borough Council/NHS Luton

     

    The context and rationale

    Background details to your example

    Summary
    The Targeted Parenting Programme for Families with Multiple Difficulties project is a joint piece of work between Luton Borough Council and NHS Luton. The model provides staff with the necessary skills to deliver and raise awareness of 'Mellow Parenting: an intensive intervention to change relationships' - as part of Luton's Parent Education Programme.

    The Targeted Parenting Programme and training has been demonstrated to reach the most vulnerable children and needy families in particular those where relationship problems approached child protection thresholds. By promoting awareness of 'Luton Mellow Parenting' amongst the wider health, social, education and voluntary sectors working with children and families in Luton, it will be possible to increase identification of high risk parents and families before they reach the child protection threshold. Prevention at an earlier stage will reduce the need for intervention across the service range as problems escalate.

    The project model has been developed to accommodate a two-phased implementation approach. Phase 1 that relates to developing the governance framework that includes:
    • clinical and patient flow pathways
    • training and education programme
    • performance monitoring and reporting tools
    • strategic implementation plan
    • process and protocol framework
    • delivery of first family group programme
    • evaluation report.

    Phase 2 of the project relates to implementation.

    Background
    It is known that children and young people account for 20% of the population. Currently there are 17,768 known children under 5 years residing in Luton. The numbers of children who are vulnerable to developing mental health problems in Luton is higher than the national average, due to the higher than average risk factors present in the locality, and the higher proportion of children in Luton’s population (28% as opposed to 25% - the national average, and which will be increasing, which is the inverse to the national trend).

    This initiative is based upon a series of evidence bases:
    • ‘Need Analysis, Consultation and Service Development Proposal – CAMH Services for under 5s’. The impact of the resulting CAMH ’Parent-Infant Psychotherapeutic Service’ has been thoroughly evaluated. This demonstrated high levels of need in the Luton under 5s population and showed that a majority of children known to services have complex, multi dimensional risk factors, commonly including maternal mental health problems and drug and alcohol issues in families with children aged 3-5 years.
    • Discussions with health colleagues and with service users, building on discussions that informed the 2008 ‘Needs Analysis’ Report, emphasised the value of training multi agency staff to deliver the Mellow Babies and Mellow Bumps courses as part of the emerging Luton Parent Education Programme.
    • A planning meeting, led by children’s commissioners and involving key stakeholders, including representatives of several local voluntary sector organisations, agreed to establish a Mellow Parenting programme in Luton from 2011-12 to meet the needs of parents with multiple needs. One or both parents had serious mental health problems and/or children were on the edge of care due to minimal parenting skills (typically arising from the cycle of deprivation where the mother would typically be a teen or young parent).
    • The interest in Mellow Parenting further grew out of the success of group work training and delivery under the Parenting Early Intervention Pathfinder for families with older children (5-13 year olds). This led to specific requests from Children’s Centre staff to train in Mellow Parenting in 2011-12 and widespread endorsement of Mellow Parenting.

    Knowledge Base
    The main evidence comes from a controlled trial of Mellow parenting in four family centres or community facilities in Scotland. This data was collected under a Department of Health grant. A brief report of this has been submitted to the British Journal of Psychiatry for publication.

    A replication of this, using a waiting list control design, was submitted, as a doctoral dissertation, University of Surrey. Uncontrolled studies describing replications are as follows:
    • Puckering et al, 1994.
    • Puckering et al, 1996.
    .• Stephen et al, ‘Mellow Parenting in Wester Hailes’.
    • Dr Jessica Brown, Sure Start Felling, Deckham, Leam Lane and Blayden-Winlaton, ‘Mellow Parenting Evaluation’.
    • Dr Jessica Brown, Sure Start, Winalton.

    Aims
    This programme is an intensive intervention changing relationships within families with multiple difficulties approaching child protection thresholds. It promotes a collaborative approach amongst the wider health, social, educational and voluntary sectors working with children and parents to keep families together and reduce the need for intervention.

    Aims
    - Build parent’s capability to make good relationships.
    - Improve child/parent interaction.
    - Improve cognitive, emotional and social development in children.

    Objectives
    - Early identification of high risk families.
    - Identify a need for further support and ensure process developed to refer/signpost as appropriate.
    - Develop evaluation/performance monitoring tools.

    Supporting principles.
    - NHS Operating Framework 2012/13 - targeted support for children and young people at particular risk of developing mental health problems.
    - Towards the Best Together, Healthy Lives Brighter Futures - commits local teams to ensuring high quality/responsive services.
    - Working Together to Safeguard Children - joint approach to safeguard and promote the welfare of children and young people.
    - Luton Children and Young People's Plan - promoting a ‘Think Family’ approach to parenting support.

     

    The practice

    Further details about the practice

    Process
    A project management approach was adopted in partnership with local systems that included development of a project charter, terms of reference and governance framework. Phase 1 related to developing the governance framework that included:
    • Clinical and patient flow pathways
    • Training and education programme
    • Performance monitoring and reporting tools
    • Strategic implementation plan
    • Process and protocol framework
    • Evaluation report.

    Phase 2 related to implementation.

    We have enabled partnership working across health, social care and the voluntary sector reducing duplication and increasing efficiencies and productivity.

    It was important to identify an effective organisational structure for the project. This provided direction, management, control and communication and ensured that the project met the needs identified which in this case was delivery of better quality care as a result of early intervention for families with multiple needs.

    A steering group consisting of stakeholders relevant to the project was established to develop a 3-year strategy and programme implementation plan.
    Steering group representatives included:
    Midwifery, Health Visiting, Clinical Psychologist, Paediatrician, Common Assessment Framework (CAF)/Lead Professional Co-ordinator, Director Stepping Stones, Luton, Service User, Children's Centres Strategy Manager, Children's Centres, Health Visitor Lead, Acting Community Service Support Manger, Early Years and Child Workforce Development Manager, Deputy Manager Greenhouse Mentoring, Paediatric Primary Care Practitioner, Relationships Team Leader, Mellow Parenting Trainer, Health Visitor Lead, Modern Matron for Children with Disabilities, Sure Start Midwife and Deputy Manager of Children’s Centre, Project Lead of the former East of England Strategic Health Authority Innovation Project, Parenting Commissioner, Hospital Matron.

    Being accountable for the development of the governance framework, it was agreed that as each element of the phase 1 model was developed it would be rolled out across the locality. This was essential, for example, where there was an urgent need to develop the performance and reporting tools to enable early collection of data and information that formed the basis of the first evaluation report.

    A key member of the steering group was the project manager, accountable to the project director, who had responsibility for the successful initiation, planning, and execution.

    An assistant psychologist was employed as a key member of the team to assist with the development of the qualitative performance monitoring and reporting tools, contribute to the development/agreement of outcome measures and undertake the evaluation of phase 1. The qualitative evaluation included:
    • Benchmarking activity and associated costs for pre- and post-programme to evidence change in patient flows/uptake.
    • Audit referral flows pre- and post-programme, evidence of increased access, care closer to home and self management.
    • Audit patient experience pre- and post-programme.
    • Audit staff experience.
    • Audit of skills.
    • Feedback from staff attending the training sessions.
    • Feedback from staff attending the ‘raising awareness’ sessions.

    Project outcomes necessitated early review of staff training needs, development of training schedule and agreement to audit/performance monitoring tools. A bespoke skills awareness course was developed and implemented across the locality as a means of alerting staff to the needs of vulnerable families with multiple complexities needing specialist support.

    A business sub-group was established and members included a Project Director/Manager, a Health Modeler and a Finance Manager. The group had responsibility for developing suitable business reporting tools and validation of performance data. Following a series of meetings where ideas and methodologies were proposed, agreement was reached to implement and test a pilot tool. Consequently data collection commenced for families that attended the first programme. The group met to review the robustness of the pilot tool and it transpired that the tool only partly met the business requirements. Having reviewed the captured data further remodeling of the tool and the referral form was necessary to meet the business objectives to evidence quality, efficiency, effectiveness and value for money. The time spent developing and testing the pilot tool was a valuable exercise because it underpinned the configuration of the business performance tool.

    Development of clinical, referral and patient flow pathways underpinned the work. These pathways ensure staff who identified vulnerable families would know why, how and where to refer the families for additional support.

    An innovative project tool, the Luton Trainers Manual provides guidance to group facilitators around their roles and responsibilities, and outlines accountability and supervision governance.

    It is anticipated that the model will fully integrate with the local Maternity Services Quality Innovation Productivity Prevention plan to commission a strategic parent education programme delivering high quality and seamless care for children, young people and their families. To ensure synergy between programmes, the project manager for the Luton Mellow Parenting is also a member of the strategic Parent Education Programme steering group.

    Project Outline

    Mellow Parenting
    Mellow Parenting is an intensive programme that is delivered one day a week for fourteen weeks. The recruitment process is crucial and it is here that we begin to nurture families, building up their self esteem by focusing on their strengths.

    Parents attend one full day each week, whilst their children are cared for in a children’s group/crèche. In the morning session parents participate in a group which provides a forum for discussing the links between their own experiences in childhood and their current parenting experiences. Lunch is prepared and eaten together (parents, children and group facilitators) which is followed by an age related activity in which parents are encouraged to play with their child. In the afternoon the parents look at videos of the interactions between parents and their children and draw out positive parenting. “Have a Go!” tasks are discussed and parents are encouraged to try our new solutions and discuss their successes.
    The programme uses video feedback from footage of the families themselves to enable us to do this in a much more direct and powerful way. Practitioners are trained to observe parent child interactions and to feed back even the embryonic skills observed as well as explaining to parents why they are important. The Mellow parent child interaction coding system, which has been developed over 15 years of research and practice, allows practitioners to objectively observe, record and feedback to other professionals, clients and the courts what they have observed. Video feedback helps parents build on their existing skills with real evidence from their interactions with their child. It is one of the key components identified in the Bakermans-Kranenberg meta analysis of effective programmes to improve parental sensitivity and parent-child attachment (Bakermans-Kranenberg et al, 2003).

    Other parts of the programme concentrate on helping parents to reflect on their own lives and relationships and to practice both in the sessions and in ‘homework [Have a Go!]’ new ways to relate to their children. We know that teaching parents to use behavioural management strategies is valuable but it is not enough in itself to change the relationships parents have with their children. It will not work if the parents have no ’internal model’ of good parenting to draw on from their own childhoods and are unable to understand their feelings and behaviour, and are burdened by their own issues.

    Mellow Parenting currently has extremely positive data from one large-scale comparison study, including data from a six month follow up, which continued to show that results were sustained over time, and a later dissertation based on an eight year follow up (Kearney, 2007). This original programme was subjected to a case-controlled cohort study, funded by the Department of Health. Neighbouring family centres offering their own parenting interventions were used as a contrast for families using family centres where Mellow Parenting was offered.

    There are numerous replication studies including some which have been able to use control groups (Renaud, 1998). Changes, not only in the UK but internationally, are regularly demonstrated by practitioners across a number of measures including: maternal depression, self-esteem, children’s behaviour, parent-child interactions and changes in the child’s cognitive functioning. In addition the programme has demonstrated itself to be extremely effective in involving and sustaining the engagement of hard to reach families with high levels of retention in the group and completion of the sessions.

    Mellow Babies
    A specialised version of Luton Mellow Parenting, based on the core principles, has been developed for parents and vulnerable babies under one year. The programme addresses both adult mental health (post natal depression) and child protection.

    The programme incorporates adult mental health, child care skills, child protection and activities suitable for parents and babies.

    The Mellow Babies programme has undergone a randomised waiting list controlled trial with clinically and statistically significant effects on maternal depression and mother child interaction, and a reduction in the need for Child Protection Registration and compulsory measures of care. Engagement and attendance at groups is very high (80% of families attended 80% of sessions).

    Mellow Bumps
    Increasing evidence of the long–term effects of maternal stress in pregnancy has led Mellow Parenting to develop an antenatal programme (Mellow Bumps) to reduce parental stress and engage the parents at the earliest stages in understanding the emotional needs of their babies. The preliminary results have shown a significant reduction in maternal stress and irritability in pregnancy. Examination of the outcomes in terms of completed gestation (40 weeks) and birth weight of the babies, both indicators of a healthy pregnancy, is currently underway.

     

    Evidence and evaluation - making a difference to children, young people and families

    Evidencing your practice has made a difference to children, young people and families

    Qualitative outcomes
    The full report (Appendix 1) titled Evaluation of Mellow Parenting Groups and Mellow Parenting Training in Luton 2011/2012 is available from C4EO team at the NFER.

    Since September 2011, Luton has successfully delivered three Mellow Parenting groups, and is currently delivering two Mellow Babies groups and one Mellow Bumps group. The evaluation process for Luton Mellow has been established and an assistant psychologist appointed. Data has been collected and analysed and video recordings have been coded. Suggestions are made on how to improve the local evaluation process, for example, by creating a Luton evaluation manual, posting information on the website and offering training or workshops to facilitators. There have been some ‘teething problems’ with the collection of some of the data, but good systems are either in place or are being developed to overcome these issues.

    Quantitative outcomes
    Appendix 2: Cost analysis and data and the referral form (Appendix 3) are available from C4EO team at the NFER

    From the outset the intention was to develop a simple tool that does not make excessive demands on the programme facilitators in order to promote data collection and maximise timely completion of appropriate forms. The referral form is integral to the performance tool.

    All members of the Business Support Group had input into the design of the tool, data entry/checking and agreed the outcomes that have been based on the data available at this early stage in the programme. As the performance tool was developed in parallel with the start of the first programme the quality of the data is not as robust as the sub-group would wish. Where it was known that families had a specific intervention but the number of episodes was not known, the sub-group agreed to adopt a conservative approach recording a single episode of care. These instances are highlighted as ‘grey’ in the ‘Family Care Pathway’ tab of Appendix 2 (available from C4EO team at the NFER).

    It is important to note that these findings may not generalise to other populations, as the data was only gathered from Luton mothers. However the results do suggest that for this population of Luton mothers the Mellow Parenting programme has been a successful intervention, thus supporting its continued delivery. The results are strongly supported by the qualitative feedback from the mothers, as shown in Appendix 1, available from C4EO team at the NFER.

    It should be noted that obtaining data for evaluation was associated with methodological issues which made statistical analysis more fragmented. They included incomplete forms from respondents. Future collection of data should overcome these methodological issues by:
    • adoption of the performance monitoring tool at the start of future programmes improving the quality of the data
    • increase in programmes and families resulting in additional data available for analysis; and
    • analysing data over a longer timeframe.

    Evaluation of the first parent programme shows good qualitative and quantitative impact on the lives of those families participating in the programme. Parent evaluation showed the following impact:
    - Social services were no longer involved
    - Reduced health interventions
    - The group helped to calm them and lower stress levels, helping sleep patterns and improving mental health.

    Mums stated:
    “It’s not until the group is over that you realise it was worked."
    “She started to play with her kids as a result of them being happier around you, and her not being so tired”.
    “It just stopped all that bad behaviour.”“It makes you step back and look rather than just moan all the time.”
    “I’m a lot more patient with my baby than I was before the course.”

    Evaluation is undertaken at the end of staff training and feedback indicated that delegates found the training interesting and informative. Comments showed that their knowledge and understanding had improved, particularly the skills to observe parent/child interaction. This was new information to participants who were not familiar with the dimensions that are often used in assessing parent/child relationships. This raised awareness of infant-mental health and gave participants skills to take away for use in their general work.

     

    Sustaining and replicating your practice

    Helping others to replicate your practice

    The training has been demonstrated to reach the most vulnerable children and needy families, in particular those where relationship problems approached child protection thresholds and therefore assumed relevant to all health and social care providers. The programme model has been developed to accommodate local adoption by other areas. The governance framework includes key tools developed under Phase 1 that can be made available for local adoption and include:
    • Clinical and patient flow pathways
    • Training and education programme
    • Performance monitoring and reporting tools
    • Process and protocol framework.

    It is critical that we continue to innovate as we design a whole health and social care approach to the delivery of parent education and support. This will ensure we improve the quality of care for our patients, while making financial savings to reinvest in frontline services.

    Our intention is to align this initiative with other key Luton Borough Council initiatives namely, Team Around the Family and Troubled Families. Adopting an integrated approach we will align the key strategies to encompass both health and local authority service outcomes together with each organisation’s national and local performance indicators. It is envisaged that the team will develop a partnership performance report for this initiative.

    This initiative has highlighted the need for health and social care professionals to fully adopt the use of the CAF process as the generic tool to access appropriate support for the vulnerable families.

    The aim is to ensure that the needs of children, young people and families who experience poor outcomes are identified early and that those needs are met by agencies working together effectively and in ways that are shaped by the views and experiences of the children, young people and families themselves.

    The Luton Mellow Parenting cost analysis is available from C4EO team at the NFER.


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