Evaluation of Baby Express in Greater Manchester

In order to (1) estimate whether BE improves outcomes for babies when compared to a group of mothers and babies who receive regular services and (2) explore how BE is being implemented in GM, we will carry out the following phases of work:

1. Development phase
This will include the following activities:

-Workshop with relevant stakeholders to map out the mechanisms of BE that create a change in child outcomes. This will inform our final research design and development of questionnaires.
-Accessing ward level data and testing feasibility of ward level randomisation. This will be used to confirm the final design.
-Recruit Assistant Psychologists and Volunteer Psychologists to support the research team.
-Stakeholder engagement event in GM.
-Set up Advisory Board.
-Develop questionnaires for collecting child outcomes from mothers at around 12 months and online survey of health visitors.
-Securing ethical approval from the National Research Ethics Service and the NHS, and R&D in each site to carry out the study and ensure that all mothers of interest will have sufficient information about the study to sign informed consent to participate in our study. This will require final versions of questionnaires and materials.
-Pilot questionnaire.

2. Baby Express evaluation
Mothers-to-be who present for their 36-week midwife appointment will be identified and recruited into our study by midwives and the assistant psychologists.

The outcome measures will be collected during a face-to-face interview when children are 12-14 months old by NatCen interviewers. If needed, we will also collect outcome data from a cohort of mothers in the BE wards and control wards whose infants were born before BE was introduced to enable us to adjust our analysis for any individual level differences between the BE and control wards. Their outcomes will be measured in much the same way as those in the trial.

We will also seek access to information about mothers' 'antenatal pathway factors' during pregnancy from the data collected as part of the Maternity Pathway Maternity Tariff Payment by Results system. This would include mothers in the BE and control areas as well as in two pre-BE cohorts.

Our approach to data analysis will be determined by whether it has been possible to randomise wards into BE and control groups. Ideally, we will compare the post-BE outcomes in BE wards with those in control wards while taking into account clustering at the ward level.

3. Health Visitor survey
We propose to gather the views and experiences of those involved in the delivery of the BE activities such as health visitors. The specific questions to be addressed will be developed in the initial stages of the project but overall, we aim explore:
-How practitioners adhered to, adapted, dropped, or altered BE delivery?
-What are the key contextual or supporting enablers and constraints in delivering BE successfully?
-What worked and didn't work in delivering BE?
-What is their overall perception of the value of BE and how well implementation is going?
-Whether/how initial delivery intentions are being realised in current operations?
-What are the challenges they have faced?
-How have these challenges been addressed?

The survey will be analysed using descriptive statistics, reported in charts and tables, and used to interpret and contextualise the impact findings from the BE trial described above.

4. Dissemination
Our dissemination plan will be agreed at the start of the project. The activities will include public engagement opportunities at various stages of our project and publications targeted at key practitioner audiences, peer-reviewed journals, seminars/conferences and other events and through media.

We outline the stakeholder groups who we expect to benefit from the research.

Families: Parents receiving BE will be equipped with knowledge and skills to understand their babies better and stimulate their development which is likely to improve child outcomes. Parents in the control group will receive standard health visitor support and other services. Parents and babies in the future will benefit because professionals will have a better understanding of effective parenting support.

Health Visiting Teams will benefit from delivering an intervention that supports the Healthy Child Programme. The teams will acquire skills to deliver BE with fidelity to the target population. Other early years practitioners (not involved in the study) in GM and elsewhere will benefit from being trained to deliver BE.

Early years staff, clinical psychologists and Midwives across all sites will benefit from engagement in the delivery of a RCT. Their involvement in this partnership project will enhance their capacity to understand and critically assess research findings and contribute to the implementation of similar evaluations in the future.

Best Beginnings, the licence holder of BE, will benefit from having strong evidence about the impact of BE which, if positive, will allow them to promote BE to commissioners, policy-makers, practitioners, potential clients and others interested in preventative interventions.

Local commissioners and policy-makers beyond GM can benefit from the GM's experience in evaluating a universal prevention programme and using the evidence from the BE evaluation to inform public policy reform, commissioning and innovative forms of financing services (e.g. payment by results, social impact bonds).

GM Chief Executives responsible for GM Public Service Reform will benefit from being involved in the project and from the evidence on BE impact on child outcomes (and costs and benefits) that will inform their decision-making on whether or not to retain BE as part of the New Delivery Model.
GM Chief Executives and economic partners will be able to use the impact estimates in GM public sector reform cost-benefit analysis, estimating the value for money of the intervention; the 'social return on investment'. The results of such analyses can influence future investment decisions on a local authority and national level.
Early Years services including children's centres: Evidence of effectiveness will promote adoption of BE by all staff groups as a single source of developmental advice, providing a common language for use with parents regarding play and interaction at an early stage.
NatCen: The partnership with GM will help NatCen to enhance their capacity to work in partnership with service commissioners and practitioners, gain expertise in implementing an impact evaluation and knowledge of health services and commissioning in a local authority context. The partnership will also cultivate working relationships that can lead to new collaborative projects in the future.
Academic/representative organisations: BE is widely endorsed, including by the Royal College of Midwives, Institute of Health Visiting, Royal College of Paediatrics and Child Health and Royal College of Speech and Language Therapy. All of these agencies will benefit from the evidence on BE effectiveness.
National policy-makers: Department of Health, NHS England and Public Health England (PHE) will benefit from evidence on the impact of BE. The Healthy Child Programme (HCP) is currently being reviewed for PHE and new evidence on BE will inform the decision on whether BE should retained in the HCP and whether there is a case for national roll-out.
Wider society: If BE is shown to be effective, providing BE as a public health prevention to the target population has the potential to offer wider societal and economic impact by not only improving child outcomes (incl. school readiness) but also allow for cost-savings over the life course of the child.