Policy Research Programme - Evaluation of trials to test innovative early years workforce models

Timetable and Budget

Description	Deadline/Limit
Deadline for Stage 1 Applications	04 October 2022, 1 PM
Notification of outcome of Stage 1 Application	13 December 2022
Deadline for Stage 2 application	24 January 2023, 1 PM
Notification of outcome of Stage 2 Application	June 2023
Project Start	June/July 2023
Project Duration	2 years 6 months
Budget	Indicative budget of £500K or higher if an exceptional case is made for additional resource

Introduction 

The Office for Health Improvement and Disparities (OHID) within the Department of Health and Social Care (DHSC) is investing £10m in trials which test and evaluate innovative early years workforce models, which incorporate a ‘skill mix’ in order to deliver universal and universal-plus Start for Life services in a small number of local authorities.

The Department of Health and Social Care invites proposals for a single research project to design and deliver a process evaluation and an impact evaluation of the trials on early years workforce models, which are being designed by OHID.This is a significant opportunity to support the Family Hubs and Start for Life programme in its aim to improve the experience of families during the 1,001 critical days and the early years, and build a robust evidence base which will inform commissioning decisions that will ensure the early years workforce is effective and families are supported.

‘Skill mix’ is defined as designing the roles and responsibilities of a team around the needs of the parents, families and babies to ensure there is the right expertise at the right level to meet those needs. Creation of a appropriate skill mix requires an understanding of:

• Babies and families’ needs,
• What skills are required to meet those needs,
• The capabilities of the workforce currently  in place, and therefore,
• What adjustment is required to the team to create the appropriate skill mix.

The aim of the trials is to understand the skill mix and supporting infrastructure needed to provide families with the universal and early intervention support they need from conception to age two, in a range of circumstances – and to understand the factors that increase the capacity and job satisfaction of the workforces involved in supporting families in this critical period.  

Findings from these trials will be shared and support commissioners across the country to make decisions about workforce planning based on the evidence of what works and best practice approaches to implementation. 

The Department intends to work with local authorities, NHS Trusts and other local partners in each selected area to ensure that an integrated approach to workforce planning and commissioning is taken, in order to make the best use of existing staff and skill sets across health and local authority settings. 

Background

Our vision is that every family will be supported by a range of professionals and volunteers offering a joined-up service, each of whom brings skills, knowledge, and empathy to interactions with families. From their first appointment, every parent and carer must feel that they are heard and that they can ask for help.  

The Early Years Healthy Development Review identified gaps in provision of early intervention support. The review recognised that health visitors are a critical part of the early years workforce and highlighted the importance of supporting health visiting, while it also acknowledged that other professionals and volunteers have a role to play. 

The Review noted that while it is a requirement to offer every new family a minimum of five health reviews, not every family receives them. This may be because some families choose not to take up the offer but, in some instances, families do not receive the offer of all five reviews. There are also disparities based on demographic and geographic factors. Evidence from Public Health England (2021) suggests  that the likelihood of receiving all mandated health reviews up to the age of one varies with ethnicity and that you are more likely to receive health visitor reviews if you live in the more advantaged areas of England.

The pandemic has had a significant impact on access to services for children and families. While many services responded quickly and adapted services in real time to support families, access to face-to-face services, referrals and diagnostics were greatly reduced. The evidence of impacts on babies, children and young people is continuing to emerge, but there are early indications that there is a particular impact on those with additional vulnerability, special educational needs and/or disabilities. Vulnerable infants are at a known risk of disadvantage and other risks, for example safeguarding risks. There have also been indications of an increased demand for mental health services. 

The aim of the workforce trials is to learn what works to ensure all parents and babies receive the universal and early intervention support they need in the Start for Life period, as well as specialist support where an acute need is identified. The areas under consideration for evaluation are wide ranging and interlinked:

• skill mix (e.g., volunteers, early years practitioners and family support workers working in integrated teams alongside health visitors and midwives), 
• multi-agency training,
• approaches to integrated governance,
• approaches to data sharing across multi-agency professionals,
• supervision and assuring quality of care,
• career progress, retention and job satisfaction, and
• impact of changes to the workforce model on wider services.

This evidence should help local commissioners make proactive, cost-effective decisions about the design of services that will meet the needs of families, in light of local circumstances and workforce considerations. The trials are currently being developed by OHID in partnership with stakeholders. Exact design will evolve over the coming months.

This is an exciting opportunity to build the evidence base that will support the development of innovative workforce models which deliver the support families need today, make caseloads more manageable, improve job satisfaction, and reduce attrition.  This work has the potential to contribute towards longer term workforce reform policies within the sector and beyond.

Research priorities

This evaluation has two key objectives:

• A process evaluation: To understand the implementation of the workforce models in a small number of local authorities, how this varies across contexts, and what works for who, where, and why. 
• An impact evaluation: To identify the impact of the workforce models on key outcomes in a small number of local authorities. These outcomes will be related to improving experiences (of staff and parents/carers), improving outcomes (around things such as breastfeeding rates, mental health issues being identified and resolved early, detection of safeguarding risks at an early rather than later stage), and longer-term reduction in disparities. 

These will assess the models against key outcomes.

A list of proposed research questions to address across the programme are set out below. We would welcome comments and additions on these questions. Although these represent examples, it will be important to consider key themes such as implementation of the models, the impact of different variables on access, outcomes and experience, and overcoming barriers.  

Overarching research questions:

• How do different workforce models impact key outcomes? 
• How were different workforce models implemented?
• What enables successful delivery? How were any barriers overcome?
• How do skill mix and supportive infrastructure impact access, experience, and outcomes for families with universal needs and vulnerable families?
• What is the experience of the workforce and impact on delivery of the healthy child programme?
• What is the impact on early identification of risk and referral to specialist services?

Implementation research questions:

• What type of key contact model has each local authority (LA) introduced? How are workforce models being implemented in local contexts? Are LAs setting up the workforce models successfully?
• What skill mix did local partners implement?
• What were the numbers of staff within each profession?
• What is the workforce’s experience of these models being implemented?
• What kinds of workforce models work well in different local contexts? 
• What are the barriers and enablers of effective delivery of health visiting services?
• How are the guiding principles implemented in practice?
• How does service delivery, experience and quality differ between contexts – and why?
• If the LA has a family hub model, how has this affected the implementation of the innovative workforce model?

Impact research questions:

Access

• What is the impact of different workforce models on the ability of families to access services they need?
• Has implementation impacted the number of referrals to more targeted/specialist services? Has there been earlier access into specialist services where required?
• What is the impact of different workforce models on seldom heard and/or vulnerable families accessing services?

Outcomes

• What is the impact of different workforce models on safeguarding outcomes for babies and families – in particular, early intervention of issues and successful, seamless resolution without the need for escalation, early identification of children/families in need of additional support and/or at risk, and reduction in disparities? 
• What is the impact of workforce models on workforce related outcomes such as productivity, caseload, satisfaction, referrals to other services etc.

Experience

• What is the impact of different workforce models on the experience of families?
• What is the impact of different workforce models on the experience of the workforce? 

Other

• Is there evidence of cost effectiveness? 
• What is the impact of the workforce models on the quality and completion rate of the Healthy Child Programme 5 mandated health reviews?
  
  

The process evaluation should focus on implementation, and the workforces experience of the models, for example through surveys and qualitative case studies. The process evaluation will enable us to understand the mechanisms by which the models are effective. It will also enable us to identify any barriers to implementing these models, especially across a range of different contexts which will support future implementation in further LAs.

The impact evaluation will establish the impact of the workforce models on key outcomes. This will be primarily on ‘upstream’ or proximal outcomes, of the sort we anticipate should be directly benefited by the models and that we should be able to observe change in, within the 2-3 evaluation year window. We encourage applicants to consider the level of impact assessment that would be appropriate within the range of time given for this evaluation.

Where possible, we would like to use quasi-experimental methods to assess the impact of the model on key outcomes. We would also like to have a test and learn approach to the trials, meaning designs should have routes for reporting initial findings built into the reporting mechanism.

We anticipate running the trials in circa 5 LAs, but encourage bidders to provide thoughts on the number of LAs that would be robust and representative to assess different workforce models in different contexts, whilst being flexible to accommodate what is affordable to implement.

We recognise that the 2-3-year time window for evaluation is initially short, and therefore encourage the evaluation to focus on the implementation in LAs and the impact of initial ‘upstream’ outcomes. This could include outcomes such as access to services, earlier identification of families in need of support and/or at risk and resolution of issues without the need for further escalation, improvements in some rates where data is regularly collected e.g., breastfeeding at 6-8 weeks, and improvements in experience of staff and parents.

If timelines and resources allow, we would welcome inclusion of an economic evaluation once sufficient data has been collected. Alternatively, we would encourage bids to consider forms of data collection that make subsequent economic evaluation possible. This could include, for example, taking a cost-benefit approach to understand relative value for money, or considering how the skills models improve the efficiency of the workforces’ allocation of skills, cost-effectiveness and subsequent impact.

New Guidance on Health Inequalities data collection within NIHR PRP Research: 

Health Inequalities is a high priority area within the Department of Health and Social Care and the NIHR and is often present in a majority of funded projects. We are now assessing all NIHR research proposals in relation to health inequalities. We are asking applicants to identify in their application whether or not there is a health inequalities component or theme and how this research hopes to impact health inequalities. We are also asking researchers to collect relevant data, if appropriate for the research. Our goal is to collect information on health inequalities in research and data relating to the main outcome(s) of the proposed research. Please clearly identify in this section whether or not your application has a health inequalities component or relevance to health inequalities and detail the core set of health inequalities breakdowns that will be reported; if none please explain why. We understand that research projects have different methodologies and focus on different populations, so please explain what data will be collected and reported for the methodology you plan to use. If a health inequalities component is not included, please explain why this does not fit within your proposed research. This should only be a few sentences.

For quantitative research we would ideally like researchers to provide one-way breakdowns of their main outcome(s) by the following equity-relevant variables: age, sex, gender, disability, region, 5 ONS Ethnic groups, and the 5 IMD quintile groups. If more detailed cross tabulations are appropriate, please include these. This table should be submitted to NIHR PRP at the end of the project. Due to data limitations, judgement calls may be necessary about which breakdowns to report and whether to merge categories to increase counts in particular cells; we ask you to make these judgement calls yourself, bearing in mind our data curation aim of enabling future evidence synthesis work in pooling results from different studies.  More details and an example table can be found in Appendix A. 

For qualitative research projects, this can be purely descriptive statistics giving the number of observations against the various variables.

Further details about this new request can be found in Appendix A. 

We will also be holding a Health Inequalities in NIHR PRP Research Q&A Event on 19 September 2022, more details in APPENDIX B.  

Areas out of scope for this programme of work 

The Start for Life programme is a £170 million package of investment which also includes strands of interventions for breastfeeding support, perinatal mental health and parent-infant relationship support, and the publication of Start for Life offers. The evaluation of the wider Start for Life investment is currently being commissioned through NIHR and is out of scope of this evaluation. This evaluation will focus on solely evaluating the £10m investment to trial innovative workforce models. There is likely to be shared learning from this project and the workforce trials research, resulting from elements of the wider evaluation exploring similar strands of the programme, such as experience of workforce. Precise details of an overall evidence synthesis will be developed when research partners are in place. 

The primary objective of this programme is to focus on understanding implementation and early impacts of innovative workforce models to inform future investment and commissioning decisions. In time we would like to understand the longer-term impacts of these models and encourage designs that enable this, but not at the expense of a focus on the next 2-3 years.

Technical requirements / Expertise required 

• Experience undertaking evaluations of trials using mixed method (qualitative and quantitative) approaches.
• Experience working with a variety of stakeholders (such as including Local Authorities (LA), early years workforce, Institute of Health Visiting, Chief Public Health Nursing Team, etc.)
• Expertise in quasi-experimental methods to identify impact.
• Experience producing outputs for a range of audiences including local commissioners and stakeholders.
• Ideally an understanding of the early years workforce (e.g., health visitors) and volunteers involved in delivering services in the first two years of life.
• Subject knowledge in the area, including the research literature around health visiting and the impact of the early years workforce/volunteers.

Outputs 

We expect an annual evaluation report on findings, and an end of programme report. 

Given the goal to test and learn from these trials, we also request regular project updates particularly in terms of service quality; the appropriate frequency can be agreed with the successful applicants, but we would anticipate updates in the region of every quarter as a minimum.

A key milestone will be the preparation for the next Spending Review, which we anticipate will start in Summer 2024. At this stage we will require an interim report on findings from the evaluation to date. Evaluation can continue beyond this point because the full findings will be used to inform guidance for commissioners (which isn’t directly linked to the next spending review – the guidance can help with local commissioning decisions.) 

Applicants are asked to consider the timing and nature of deliverables in their proposals. Policymakers will need research evidence to meet key policy decisions and timescales, so resource will need to be flexible to meet these requirements. A meeting to discuss policy needs with DHSC officials will be convened as a matter of priority following contracting.

Budget and duration 

Applications will be assessed on value for money, and we have suggested an indicative budget of  £500,000; there may be additional funds available if an exceptional case is made for additional resource. The proposed spend on the trials themselves (separate to the evaluation) is £10m across financial years 23/24 and 24/25.

The project is expected to start in Summer 2023 and we envision the project will take 2.5 years.

Costings can include up to 100% full economic costing (FEC) but should exclude output VAT. Applicants are advised that value for money is one of the key criteria that peer reviewers and commissioning panel members will assess applications against.

Management arrangements

A research advisory group including, but not limited to, representatives of DHSC, other stakeholders, and the successful applicants for the research should be established. The advisory group will provide guidance, meeting regularly over the lifetime of the research. The successful applicants should be prepared to review research objectives with the advisory group, and to share emerging findings on an ongoing basis. They will be expected to:

1. Provide regular feedback on progress
2. Produce timely reports to the advisory group
3. Produce a final report for sign off

The successful applicant will be expected to work with nominated officials in DHSC, its partners and the NIHR. Key documents including, for example, research protocols, research instruments, reports and publications must be provided to DHSC in draft form allowing sufficient time for review.

Bids will be assessed on deliverability, so we encourage applicants to set out how their proposed team and management structure (including staff time) will enable the completion of a high-quality project.

References and key documents

1. HM Government. The best start for life: a vision for the 1,001 critical days. 2021. Available from: The best start for life: a vision for the 1,001 critical days 
2. Start for Life policy announcement: Infants, children and families to benefit from boost in support 
3. Institute for Health Visiting. State of Health Visiting Annual Survey. 2021. Available from: State-of-Health-Visiting-Survey-2021-FINAL-VERSION-25.11.21.pdf 
4. Public Health England: Characteristics of children receiving universal health visitor reviews

Appendix A: Further Detail on the New Guidance on Health Inequalities data collection within NIHR PRP Research

Health Inequalities is a high priority area within the Department of Health and Social Care and the NIHR and is often present in a majority of funded projects. We are now assessing all NIHR research proposals in relation to health inequalities. We are asking applicants to identify in their application whether or not there is a health inequalities component or theme and how this research hopes to impact health inequalities. We are also asking researchers to collect relevant data related to health inequalities, if appropriate for the research. Collecting specific information about health inequalities in research submitted to the programme will allow for categorisation of health inequalities research, curation of data to aid future health inequalities research and enable policymakers to better understand the implications of health inequalities within their policy areas. This is a new request from the NIHR PRP and we will be continuing to monitor queries and adapt the process as needed. If you have any feedback on this new request, please contact us at prp@nihr.ac.uk. 

Our goal is to facilitate more widespread and consistent reporting of health inequality breakdown data relating to the primary outcomes of NIHR funded research. We would ideally like researchers to focus on the following equity-relevant variables: age, sex, gender, disability, region*, 5 ONS Ethnic groups**, and the 5 IMD quintile groups. These variables are considered an ideal, but we understand that these are subject to change depending on the sample population and specific research question.  

For qualitative research projects, this can be purely baseline characteristics of the participants, for example, the number of participants in each ethnic group. 

For quantitative research projects, if there are multiple outcomes/effects with your stakeholders, select a small number of main outcomes as appropriate to report equity breakdowns. We will not be prescriptive about the number of the outcomes, as it will depend on the number of study design types and the nature of the project aims. We are asking for one way cross tabulations of each primary outcome by these equity-relevant variables, if appropriate for your research, together with the number of observations in each cell. If more detailed cross tabulations are appropriate for your proposed research, please include these as well. This request applies to both primary data collection studies and secondary analysis of routine data, and to causal inference studies as well as descriptive studies; however, if this is not possible due to data limitations then please explain. Due to sample size and other data limitations there may be difficult scientific and/or data security*** judgement calls to make about which breakdowns to report and whether to merge categories to increase counts in particular cells; we ask you to make these judgments yourself, bearing in mind our data curation aim of enabling future evidence synthesis work in pooling results from different studies. We also ask that researchers report breakdowns for the unadjusted as well as adjusted outcomes/effects, as appropriate.

We understand that research projects may employ different methodologies, and focus on different populations. Please explain how the variables and data collection methods chosen are appropriate to the methodologies used. 

We ask that you please clearly identify in the research plan section of the application whether your application has a health inequalities component or not and detail the core set of health inequality breakdown data that will be collected, if applicable. Submission of the data collection will be a condition of the final report for all research with relevant methodologies regardless of whether the research has a health inequalities component that will need to be submitted to NIHR PRP when the grant has finished. This should only take a few sentences within the research plan section. 

* Table below uses the nine regions in England, further regions can be used if using the UK as the study population. Please report region breakdown for large samples in nationally representative descriptive studies. There is no need to report this for small sample studies, for sub-national studies, or for quasi-experimental studies where it would require time-consuming re-estimation.

** White, Mixed/ Multiple ethnic groups, Asian/ Asian British, Black/ African/ Caribbean/ Black British, Other ethnic group. If the sample size is small then it is fine to report only some of the requested equity breakdowns and to merge some of the sub-groups as appropriate.

*** For guidance on how to handle data security concerns in reporting of sensitive data please see ONS guidance.

Example data table for submission at the end of the funded research project

(N.B. If there is more than one main outcome then you will require more tables and if you adjust your outcome then you will need two tables for the adjusted outcome and unadjusted outcome. For other methodologies, variable vs number of observations may be more appropriate to record participant data). This table is for an example only. It does not contain sub variables and does not illustrate any preference for certain variables, as these will be dependent on the proposed research.

Variable		Outcome (an appropriate average for this subgroup, usually the mean)	Number of observations	Additional information about variation if appropriate, e.g. range, standard deviation
Age		-	-	-
Sex		-	-	-
Gender		-	-	-
Disability		-	-	-
Ethnic Group		-	-	-
IMD Group		-	-	-
Region		-	-	-

Appendix B: Health Inequalities in NIHR PRP Research Q&A Event

This event will take place on Monday, 19 September 2022 from 2:00 - 3:00pm. There will be a discussion from the NIHR PRP, the Department of Health and Social Care and other panellists followed by the opportunity for a Q&A session to help applicants navigate this new request. Please register for the event using the google registration form for the event. Any questions that are not answered during the session will be anonymously answered and published in a FAQ document on the health inequalities webpage.