In November 2012, the new Institute of Health Visiting was launched at the RSPH headquarters in Portland Place. Over 1,000 new health visitors have already been trained under the coalition government and 3,000 more will be trained in the next two to three years.

This year, in 2013, our milestone conference was the first joint event from the Institute of Health Visiting with founding partner RSPH.

The aim of the 6 June conference was to 'join the dots' between:
  • the growing research base demonstrating that future mental heath is most usually determined by what happens to an individual during the period from conception to two years of age
  • the clear public health implications of this for society
We know that from conception to two years is a critical period for early intervention and prevention, and most mental illness is preventable. It is essential that more resources are directed at improving the emotional wellbeing of infants and their families.

The Institute of Health Visiting with RSPH assembled some of the most eminent speakers in this field to discuss the research, the economic case and its implications for public mental health. The effects of austerity make public health measures and health visiting more vital than ever for the wellbeing of our children and our communities. We are delighted that the conference programme was so well received by delegates. We look forward to working with all of those who participated in the conference to tackle the issues we discussed and implement the best programmes and interventions available.

Cheryll Adams Shirley Cramer CBE Director Chief Executive Institute of Health Visiting Royal Society of Public Health

Conference Themes and the Implications for Public Mental Health

This section offers an overview of the main themes arising from the conference and the implications for public health. It brings together  issues raised by the speakers in their presentations, the discussion in the question and answer sessions  the panel contributions during the final session of the conference.

Theme 1
Identifying the evidence base for the impact of early experiences during pregnancy and the first two years on infants and young children
‘Physical care in pregnancy is pretty good. Now we must change the emphasis and the climate so that we put the emotional care of pregnant women first.’ Professor Vivette Glover, 2013 conference, Healthy Young Minds, Healthy Communities.

Speakers such as Professor Vivette Glover and Sue Gerhardt presented the latest research findings showing how crucial a period is pregnancy and the first two years.

Glover presented the latest research showing that experiences before birth affect the growing baby. What happens to the mother impacts directly and immediately on the unborn baby. Pre-natal depression is of concern in 15% of pregnant women.

Pre-natal stress can affect the unborn baby by increasing the tendency in the baby after birth to difficulties such as anxiety and depression, behaviour problems, impaired cognitive development, sleep problems, a more difficult temperament, being bullied, schizophrenia and autism. The evidence shows that sensitive parenting and mothering after birth can counter these effects. More research is underway looking at the evidence for whether changes prebirth can be reversed after the birth.

Human babies are unique in their total dependency at birth.  A huge amount of development remains to happen after birth as the brain continues to grow. What happens after birth is as important as what happens in pregnancy. The interactions between parents and their baby, especially the mother and baby, quickly build into the vital two-way communication that gives each baby a secure sense of place in the world. These interactions help the baby’s brain develop fully. In turn, this lays a secure foundation or attachment for wellbeing in adult life. Securely attached babies grow into adults with the emotional resilience to deal with adversity. Gerhardt highlighted one of the most important skills for health visitors as the ability to analyse and understand parent-infant interaction. This understanding helps the profession with early identification of difficulties, when there is a good chance of helping the mother-baby relationship onto the right track.

Theme 2
The implications of the evidence for health visiting practice

‘The key task for most industrialized western nations now is to ensure that parents can provide the kind of parenting that supports secure attachment.’ Professor Jane Barlow, speech to 2013 conference, Healthy Young Minds, Healthy Communities.

Professor Jane Barlow explained how the evidence base for early intervention is being used to devise new programmes and approaches. The conference heard about new programmes in place for antenatal classes, showing parents-to-be how to prepare for parenthood. New developments include an app for health visitors from Warwick University, backed up by a website for practitioners.

Barlow highlighted the role of health visitors in delivering these group programs, enhanced by individual interviews in pregnancy with a positive focus on the developing relationship with the baby. At the heart of good health visiting practice and support for families in the future will be  an understanding of how important it is to work with mother and baby  training for health visitors to deliver video interaction feedback with families  more infant psychotherapy  parenting programmes delivered by health visitors.

The discussion at the conference clarified when support for pregnant women should begin. 12 weeks is the earliest opportunity for health visitors to approach a pregnant woman, and later in the pregnancy there are other opportunities. However, it was noted that the reality of service delivery in the NHS today is that new developments may be harder to implement when resources and staff time are scarce. Theme 3 The public mental health implications of the evidence for policy makers ‘Secure emotional health is the big challenge for health in the 21st century, just as physical health was in the 20th century.’ Andrea Leadsom, MP, speech to 2013 conference, Healthy Young Minds, Healthy Communities.

‘The societal and cultural factors regarding child abuse across the spectrum, and especially at the softer end of the spectrum, are not talked about. It is still taboo.’ Dr Jonathan Campion, Director for Public Mental Health and Consultant Psychiatrist, 2013 conference, Healthy Young Minds, Healthy Communities .
Andrea Leadsom MP gave the opening speech of the conference. She reminded delegates that babies need to be educated, healthy and securely attached to have the best chance of growing up with healthy young minds and the emotional resilience required to deal with the inevitable challenges of adult life.

Later in the day, Dr Jonathan Campion outlined to the conference how more adults have mental health problems than can ever be helped by the available services, thereby making the strongest case possible for a public health approach to mental health, wellbeing and healthy communities. Leadsom argued a powerful case for improved support for parents and families. Parents with babies age 0-2 need more support than is available from services right now so that they can lay the secure foundations, or attachment, that babies need to thrive. Postnatal depression potentially affects families from all walks of life. This country needs a scaled up, more cost-effective programme of support for families with babies age 0-2.

Campion concluded that prevention, promotion and early intervention for mental disorder can  sustainably reduce the burden of mental disorder  improve a range of outcomes  produce significant savings, although significant costs arise from lack of such investment.

Theme 4
The implications of the evidence for commissioners ‘There are 55 new studies coming through now for improving adult social care. I mention this as a good strategy for improvement and implementation.’ Martin Knapp, Professor of Social Policy, London School of Economics, speech to 2013 conference, Healthy Young Minds, Healthy Communities.

Knapp highlighted the impact of the recession for the worse on public mental health. He argued that it is more important than ever in a time of scarcity that we find effective interventions to support parents and babies that are also cost-effective, while highlighting that currently about 25% of evaluated interventions are evidenced as cost-effective. Risk and protective factors are especially important during pregnancy and the early years.

Interventions have greatest impact during this period of early life. Effective public mental health promotion and prevention requires interventions targeted in a universally proportionate way,  delivered through a sustained and co-ordinated government approach, in partnership with non-government organisations and communities. More than one million children in the UK suffer from neurodevelopmental disorders. 10-15% of those disorders are attributable to prenatal stress. Reducing stress, anxiety and depression in pregnancy has the potential to reduce the number of affected children in the UK by 100,000-150,000.

Theme 5
The implications of the evidence for parents and families

The discussion sessions throughout the conference highlighted the need to offer parents support in a ‘user friendly’ way, so that the majority of parents understand the help and support on offer from the health visiting profession.

The evidence for laying a secure foundation in the early years can help parents to: realise that it is normal to need support when a baby is born and that health visitors are the people who offer help at home  be sensitive and attuned to their baby  understand that there is no blame attached to themselves for events outside of their control  learn or improve the skills needed to help and love their baby.

Next Steps

The panel discussion rounded off the conference with responses to the question of how we can individually and together help to strengthen the emotional well being of society.

Three main action points were identified by panel contributors and in discussion with delegates. The health visiting profession is a key group of leaders and influencers who will deliver improved public mental health in our communities Health visitors need to be leaders and influencers. Small organisations and health visitors in localities can be audacious, can make a difference and social conditions do improve over the longer term. In localities, health visitors should engage with the Clinical Commissioning Groups for the greatest influence.

At a national level, the Institute of Health Visiting with its partners such as the RSPH needs to punch above its weight and ensure that its voice is heard by government. Combat poverty and improve public mental health at an individual and societal level The Institute of Health Visiting and its partners are in an excellent position to appeal to women in the professions to combat poverty.

Health visitors work with individuals to combat the societal impact of poverty. Combatting poverty is needed to ameliorate and protect families and children from the impact of adversity on public mental health. Seize the time now, when there is the opportunity to redesign health visiting so that it continues to be about people. The health visiting profession needs the support of parents to deliver improved public mental health. For example, health visitors are setting up social enterprises that include peer support schemes offering training for parents. This is one new way to continue to deliver the highest standard of professional, preventative services.
The period of pregnancy to 2 – a major societal issue, Andrea Leadsom MP Health visitors are the key to a good start in life for all babies because they help parents, especially mothers, to love and help their own babies. Government should enable pooling of budgets for health visitors, midwives and other support professions so that data sharing can happen easily and routinely.

Currently there is nothing in law that prevents health visitors sharing live birth data with Children’s Centres and other local services. The new All Party Group for Conception to 2 years is producing a cross party manifesto with the aim of getting the same policy asks into the manifestoes of all four main parties at the 2015 general election. It all starts in pregnancy – the powerful impact of stress, Professor Vivette Glover, Imperial College Professor Glover described the findings from the Avon Longitudinal Study of Parents and Children (ALSPAC) involving 14,000 pregnant women. The study is about the affect of antenatal stress on child behaviour in humans. The study found that the attributable load of behavioural and emotional problems in the whole population due to antenatal anxiety and/or depression is 10-15%. In the presentation, Professor Glover suggested that the unborn baby’s response to the mother’s stress may have an evolutionary benefit, in the past and now. For example, the ability to understand things in a different way (autism), to be more vigilant (anxiety) and to willingly explore new environments (impulsive) are all assets in a hostile, new or rapidly changing environment.

Interventions to reduce stress, anxiety and depression in pregnancy could reduce the number of children affected by neurodevelopmental disorders by 100,000-150,000. From neurons to neighbourhoods, why love matters, Sue Gerhardt, ‘Author of Why Love Matters’ Now is a good time to ask whether we should prioritise infant mental health services. There is a cost to not prioritizing. The total cost of treating depression and related health problems to the NHS is £9 billion a year. Changes in working life mean parents are expected to put work before babies and children. Yet prevention and change for mothers is possible, as demonstrated by successful programmes such as the Family Nurse Partnership.

At the heart of secure attachment lies responsive interaction face to face from birth between mother and baby and father and baby. What does the research tell us about effective interventions in infancy? Professor Jane Barlow, Warwick University Health visitors are delivering the most effective programmes to help and support parents. The programmes can be delivered antenatally and in Children’s Centres through a mix of home visits and groups. They help parents to become more attuned to interactions with their baby, to avoid conflict in their relationship and to offer positive parenting. The most effective methods of supporting parents include interacting with, or observing, their baby opportunities to practice new skills responding to individual concerns raised by each parent. An offer of universal and targeted evidence-based interventions requires a high level of practitioner skill and training.

Provided from Children’s Centres, these interventions work with the interaction between parent and baby and with mothers and fathers and include before and after assessments. The economics of early intervention, Martin Knapp, Professor of Social Policy, London School of Economics Economics is important for policy makers because choices have to be made about the allocation of scarce resources. Professor Knapp described the findings from the South London Child Development Study to illustrate how economics can assist in choosing the most effective and cost-effective interventions.
The study identified prenatal and postnatal depression in a mother as a factor that increases the chances of childhood developmental problems such as emotional problems, conduct problems, low IQ and special educational needs. The projected costs to the UK across the whole population are estimated at £61 million in government costs, £28 million lost in productivity and £76 million in quality of life impairments. The study found that breastfeeding and the mother’s IQ are significant factors in whether children do experience developmental problems. Research has shown that psychological interventions delivered by health visitors to prevent perinatal depression are likely to be highly cost-effective.

Professor Knapp rang a warning bell that the effects of the recession will worsen mental health across the population. Even cost-effective preventative measures will struggle to find budget allocations, at a time when they are needed more than ever. Public mental health- taking a whole society approach, Dr Jonathan Campion, Director for Public Mental Health and Consultant Psychiatrist  Mental disorder is the largest single cause of disease burden with significant impacts and economic costs.

The majority of mental disorder arises before adulthood. Risk and protective factors are particularly important during pregnancy and early years. Interventions to address risk factors and promote protective factors have greatest impact during this time. Health visitors have a key role in coordination with other organisations. A public mental health approach is important because  1 in 4 adults are affected by a mental disorder and most don’t get help. 50% of mental illness starts by the age of fourteen years old. 75% of mental illness starts by the early twenties. Even if everyone with mental health problems (that’s a quarter of the population) received help, it would still only improve 28% of that group. That’s why a public mental health approach is the only solution to help the majority of that group. Promoting emotional wellbeing in families – why health visitors can strengthen whole communities, Lord Victor Adebowale, Chief Executive, Turning Point .

There is only one question. Why aren't we doing anything about the evidence we have that proves the need for more health visitors and the effectiveness of early intervention? Health visitors will be needed to fill the gap left by other service cuts and increased demand dues to austerity measures and welfare reform.
Turning Point delivers a holistic support service to families that impacts far beyond the initial individual contact or referral point, which is addiction to alcohol and or drugs. The wider benefits to families include reduced stress and isolation for the spouse or partner of the individual, less tension at home for all family members, more involved parents and more emotionally available parents.