Better Births, social prescribing and patient safety

Since 2016 the Improving Me partnership has championed social prescribing, often referred to as ‘more than medicine’ or non-clinical interventions to promote wellbeing. This was a response to ‘Better Births - A Five Year Forward View for maternity care’. It was an opportunity to both promote a prevention agenda and to foster innovation to support new treatment and management opportunities. Initial work focused on scoping out opportunity for ‘asset based’ working through ‘New Ways of Seeing-New Ways of Doing’. This early work then informed developments and a series of collaborations with both local, regional and international partners. This early work also helped identify clear links between health inequalities and gender.

Social Prescribing Concordat for Creative Health

Improving Me developed and launched a Social Prescribing Concordat for Creative Health for the then Cheshire and Merseyside Health Care Partnership (HCP), as part of dedicated NHS70 celebrations in July 2018. The concordat outlined the role and contribution of social prescribing in reducing health inequalities; whilst capitalising on innovations from better cross-sector collaboration and partnership. The concordat was adopted by the HCP and all local authority public health teams, the Institute for Health Visitors and the Innovation Agency (AHSN).The concordat was based heavily on Marmot principles, and equally translates into an Altogether Better agenda. It uniquely positioned with women’s health and maternity central to addressing health inequalities.

Women's and Children's Symposium

The NHS70 programme included a Women's and Children's Symposium featuring contributions from academics and practitioners on perinatal mental health, language and literacy development, as well as case studies and best practice from women and families with lived experience.

Evidence Based Creative Health Solutions

The symposium provided a platform for sharing evidence on the value of non-clinical interventions for perinatal mental health, particularly the finding from Music and Motherhood. This project, led by Dr Daisy Fancourt and Dr Rosie Perkins, investigated the effectiveness of creative interventions as a psychosocial tool to reduce the occurrence and effects of post natal depression(PND). It used a randomised control(134 women) supplemented by a cohort study of over 2,000 women tracking the interactions between mental wellbeing, symptoms of PND, and involvement in creative activities in women during pregnancy and the first year of motherhood.

The findings:
• For women with moderate-severe symptoms of PND, weekly singing led to a significantly faster improvement in their symptoms than play or usual care alone
• By week 6, these mothers in the singing group had experienced a decrease of nearly 35% in their symptoms of PND
• Singing led to greater decreases in stress hormones and greater mother-infant bonding than other social interaction
• 67% of the participants no longer displayed moderate-severe symptoms.

Maternal mortality and ethnicity

The symposium supported a wider Improving Me exchange with both Dr Daisy Fancourt and Dr Rosie Perkins. This led to a collaboration to capture wider evidence as to the benefits of specific creative health interventions for women and children throughout a life course. The outcome was The Women and Children’s Creative Health Handbook -Wellbeing by Design and a series of pilot activities exploring the wider use of music and spoken and written word to address social isolation anxiety and depression in the light of an increasing awareness of perinatal mental health being a significant public health concern.

Post-natal Depression, Preterm Birth, Infant Mortality and Infant Feeding

The scoping work underpinning social prescribing developments served to highlight just how connected these key priorities are and how important the wider determinants of health are in the way these play out for all women but particularly our most disadvantaged and vulnerable women and families.

Improving Breastfeeding Rates and Duration for All-Holding Time

Breast feeding rates are much lower for women from lower socio-economic groups. The health benefits of breastfeeding for both the baby and mother are well documented. Breastfeeding is linked to a lower incidence of postnatal depression. Hear about this from our academic collaborator, Dr Vicky Fallon here. There is also a well evidenced link between mothers from disadvantaged backgrounds and the increased likelihood of preterm births (David Taylor Robinson et al) and our Baby week collaborator Dr Phil McHale. With preterm birth comes both physical and intellectual developmental delays. Milk formula comes at a substantial cost in poorer households. It is estimated it costs in the range of £800 a year. Formula is much more difficult for babies to swallow than breast milk as the fat content is less graduated and this can add to complications for new unsupported mums and babies with increased feeding challenges.

The WHO advise that the most socially isolated mothers may feel marginalized by our health services so that they feel excluded from the health care system and are not willing to seek support. They require different approaches to help them feel empowered and to increase their self-esteem. Improving Me believe we have to learn how health services can better improve breastfeeding initiation rates by mothers in all socioeconomic groups in order to reduce health inequalities from birth. Hence a unique NHS funded breastfeeding pilot, Holding Time was commissioned in 2020 to look to address the cultural stigmas surrounding breastfeeding; whilst creating meaningful engagement opportunities for the healthcare system with new mums that directly increased health literacy, peer support and women’s agency. This project uses social media and women’s voices to articulate clear messages about challenges and how to address them. You can access the podcast here.

Intersectionality-Gender and Ethnicity

Perinatal mental health affects up to 20% of women at some point during the perinatal period and can have an adverse impact on the healthy emotional, cognitive and even physical development of the child, with serious long-term consequences. Significantly, it is reported by MBRRACE-UK as the leading cause of maternal death in the first postnatal year.

The 2021 MBRRACE report also highlighted ‘the stark disparity in maternal mortality rates between women from Black and Asian aggregated ethnic groups and White women – more than four times higher for Black women, two times higher for mixed ethnicity women and almost twice as high for Asian women. Apart from a slight drop in the maternal mortality rate for Black women, this bleak picture has not changed in over a decade.’ (Page 1 MBRRACE-UK Foreword - Saving Lives, Improving Mothers’ Care 2021).

Health Justice Agenda

In October 2018, Improving Me set up a national cross sector Women's Roundtable for women thought leaders committed to making a difference for all women and children through collaborative action. The focus of the first session was to consider how to ensure: access to safe, high quality and equitable services; to support informed choice and to deliver care closer to home, with wellbeing as a driver. This work led to a series of collaborations with Dr Mary Ann Stephenson at the Women’s Budget Group. Rsaling Bragg at Maternity Action and Dame Professor Hazel Genn at University College London (UCL).

Socio-economic disadvantage, pre-term birth and infant mortality

This work served to highlight the gendered nature of poverty and the importance of addressing socio-economic disadvantage particularly in light of the strong correlation between social deprivation and levels of preterm births and infant mortality.

It led to a HCP wide investigation into the benefits of adopting a health justice agenda as part of social prescribing developments (Information and Advice on Prescription) and ultimately the establishment of a UCL and Ministry of Justice 3 year pilot with Wirral CAB’s social prescribing team. The North West Population Health and Prevention Network (Health Education England)has highlighted this regional work through a national webinar - Access to Justice - A Public Health Issue. Most recently through a partnership with Maternity Action Improving Me has subsequently funded a ground breaking trial at the Wirral Women and Children’s Hospital, where mothers have direct access to an employment lawyer who can give them advice on everything from access to benefits, maternity pay and how to deal with unfair or unsafe working conditions.

Workforce Development

This roundtable led to a number of agreed actions one of which was to develop a pilot activity across the North of England to explore the impact of a social prescribing principles in a maternity context, specifically in terms of Maternity Support Worker (MSW) workforce development. A successful bid was submitted to HEE and work commenced to realise a Health Education England (HEE) MSW pilot focused on the HEE career development framework and in spite of COVID interruptions, a new Level 3 award was launched which delivered a successful cohort in 2022.

Creative Health

A number of challenges were identified through the NHS 70 symposium and the round table for the delivery of safe, effective and personalised care for women and children and a programme of activity was initiated to address these through a funded creative health programme. This work was focused on particularly vulnerable women where language barriers or lack of trust reduced the capacity for self- care and active engagement with NHS services and it provided a direct response to MBRRACE data.

ESOL Stepping Stones

A cross sector partnership was brokered and developed between the University of Manchester, Liverpool Libraries and the WEA; on behalf of Liverpool Women's Hospital midwifery team and Improving Me’s prevention team; to address a number of challenges simultaneously. These included the establishment of a community hub at Toxteth library for women where a lack of English was/is a barrier to accessing services, the development of an accessible community Baby Box distribution point; a dedicated learning programme called ESOL Stepping Stones for women and babies (or bumps)with English language needs, which included a focus on self-care and health literacy; wrap around community led social prescribing provision which addressed perinatal mental health and attachment and bonding needs through a regular rhyme time and social gathering opportunity; strong links to Maternity Voices development; and additional free family learning opportunity to address wider family needs. This model was then emulated in St Helens and linked to an established language and literacy programme (BLUSH) for older siblings with a view to breaking the cycle of low educational opportunity feeding health inequality. Unfortunately, COVID and devolution, which impacted on ESFA funding, severely interrupted these ESOL developments.

However, during lockdown new funding was identified through the Combined Authority and the original programme was resurrected with an additional health student placement programme attached. More recently as part of COVID recovery the learning from ESOL Stepping Stones was translated in to three perinatal mental health music pilots in libraries (St Helens, Knowsley and the Wirral) - the Music Connection led by The Royal Liverpool Philharmonic; in conjunction with three local social prescribing services which are pioneering developments for perinatal mental health specialist link workers.

System blockages due to the limited availability of community interpreters are also being addressed through these initiatives. The development of volunteers for the programme is a high priority with an emphasis in supporting women with lived experience to engage with both Maternity Voices and the Stepping Stones activity to support women's personal development and promote community integration. It is anticipated this work will contribute to growing a future NHS workforce with a ready supply of aspirants with the right skills and values.

In 2021, the ESOL Stepping Stones programme was resurrected post COVID this time in collaboration with both libraries and National Museums Liverpool.

Nurse training and development activity

A national special interest group (SIG) for social prescribing and nursing was convened in January 2018. A steering group was then set up in the February. This steering group includes strong representation from the Improving Me Partnership and there is a clear focus on the implications of adopting a personalised care agenda for women's and children's services. The SIG steering group is also linked to the national Women's Roundtable. The SIG chair, Dr Michelle Howarth and the Improving Me representative, Jo Ward have been tasked in making representations to key professional nursing groupings at a leadership level to build a commitment to transforming the workforce. The SIG has now also taken forward a commitment to explore how to promote personalised care through the adoption of social prescribing principles and practice, unique placements and curriculum design.

The SIG will deliver a national conference at the end of 2019 with inputs from NHSE and HEE. The new NMC Standards for Pre-registration Nurse education provides an opportunity for HEIs to redress balance between medical and person centred models and promote a salutogenic philosophy to enable students to explore meaning of person and patient centred care. Explicating the personalised agenda within the curriculum will also help students to explore and describe theories of health and wellbeing related to personalised care and how these influence shared decision making to self-manage based on what matters to the individuals. This work in turn provides a platform to shape nursing CPD and inform the development of a focus on Maternity Support Workers across the North of England. This work sits alongside and will support a successful bid In January 2019 to HEE pilot to develop a new style curriculum for Maternity Support Workers in the North of England, aligned with social prescribing principles and practice and designed to support progression into healthcare professions, reflecting a Talent for Care agenda.

Through direct engagement with a national Medical Education SIG and a subsequent focus on the role of a creative health agenda in a secondary care context the Improving Me Partnership have submitted a proposal to the Innovation Agency for a symposium to bring Yale based academics to Liverpool to highlight how a creative health agenda can help support clinicians undertaking a reflective approach to self-evaluation of their clinical learning, as well as responses to feedback from clinical placements, patients and formal assessments. This symposium will also showcase innovations in the treatment and care of children where there is clear evidence of the value of a ‘more than medicine agenda' in both treatment and recovery in order to inspire further innovation.