FeaturesHV tools: reach for the stars

HV tools: reach for the stars

Sam Game asks how we can show impact and measure the value of health visitors’ work with families using Outcomes Stars.

South Warwickshire NHS Foundation Trust provides the 0 to 5 public health nursing service within the county. With multiple teams of health visitors covering 760 square miles and around 30,000 children, we are very much aware that need varies between caseloads and geographic areas.

We needed to find a way to collect data easily and effectively, and to measure and demonstrate health visitors’ value and impact following their work with families.

In 2018 we started to explore whether the Outcomes Star suite of resources created by the Triangle organisation could help us with this. After some discussion, we chose to start with the newly published Parent and Baby Star, designed to support perinatal mental health and wellbeing.

What is the Parent and Baby Star?

The Parent and Baby Star is both a keywork tool to support effective interventions and an outcomes tool that gives management data on progress towards the end outcome. Because of this dual role, it brings together measurement and service delivery and can provide a shared language and framework across operations and data management for departments and between commissioners and service providers. It also employs a ‘done-with’ not ‘done-to’ model, and so is person-centred – giving service users a central role in creating a shared perspective around their strengths, areas that need work and the type of support that is needed.

The Parent and Baby Star assesses seven outcome areas arranged in the shape of a star (see Figure 1). The Parent and Baby Star has a five-point scale, using a model of change (the Journey of Change) that describes steps towards the end goals of both the service and service user. Each point on the scale has detailed descriptors setting out the attitudes and behaviour typical of that point on the scale.

How is it used?

At the beginning of 2019, all 115 HVs within Warwickshire undertook a joint training initiative with Triangle. Initially, eight training sessions were completed, leading to 115 licences being issued to staff. The standard operating procedures were written and agreed by senior management. This stated that the Parent and Baby Outcomes Star tool would be used with all parents at the six-week postnatal review. HVs were already carrying out a six-week review as part of the mandated visiting schedule, so this ensured the tool’s implementation was operationally feasible.

From October 2021, this was expanded to include the antenatal visit as well as the six-week review. The Star readings give us two pathways for families: if families have readings of 4 or 5 in all areas, they are deemed as Universal (needing five mandatory contacts only) and advised how to contact the health visiting team if they require further support and when their next mandated contact will be. If a parent’s star reading is 3 or below in any area, then an intervention would be offered, followed by a review star looking at progress. The type of intervention would be negotiated between the parent and the clinician at the time of the reading.

Using the Outcomes Star training and user guides (Burns et al, 2018) with families provides a consistent and holistic asset-based approach, ensuring a mother with a star reading of 3 in Nuneaton would be showing the same needs as a mum with an identical reading in Stratford. This allows us to assess need quickly and simply across the county, with the aim of operationally using this to ensure service needs are met.

What are HVs’ views on Outcomes Stars?

Warwickshire was the first health visiting service in the UK to use the Outcomes Star format in practice. To ensure accurate and useful data when implementing the Outcomes Star system, an agile implementation model with regular reviews was agreed upon.

Using the outcomes Star training and user guides with families provides a consistent and holistic asset-based approach, allowing us to assess need quickly and simply

The first full audit was carried out with staff after they had used the Parent and Baby Star for one year. The aim of the audit was to review how effective the Outcomes Star was from a staff and parent perspective. All staff with active Star licences were sent a Google Forms questionnaire to complete regarding their experiences and opinions of using the Parent and Baby Star.

  • 42% of HVs responded.
  • 98% of HVs who answered the questionnaire were using the Parent and Baby Star with families at the six- week postnatal review.
  • 76% of HVs said that using the Parent and Baby Star gave a clearer picture of the lived experience of a family.
  • 80% of HVs would recommend the Parent and Baby Star to HVs outside Warwickshire.
  • When asked how effective it was as a tool at six weeks, 63% of HVs said ‘effective’ or ‘very effective’, while others felt there was scope to use it more effectively.

Following the audit and staff input, it was decided to expand the Parent and Baby Star to include antenatal assessments.

HVs told us about using the Parent and Baby Star:

‘It made it easier to focus on the important issues and ask relevant questions’

‘The pictorial charts help to explain what it’s all about, and within our discussion it works well’

‘Completing the Parent and Baby Star has helped several parents’ communication’

‘It helps parents to self-assess, which increases their confidence, breaks down barriers and aids further support being accepted.’

HVs also told us:

‘Sometimes completing the star opens up a deeper conversation as a result of a reading that I didn’t anticipate’

‘One or two have surprised me by admitting they did not feel they had connected with their baby, while on the surface all appeared well’

‘Using the Parent and Baby Star made it easier to focus on the important issues and ask relevant questions’

‘Helping parents self-assess really increases their confidence and breaks down barriers if support is needed.’

Parent feedback

We asked parents how they found using the Parent and Baby Star.

They told us:

‘It helped me feel I mattered, as it wasn’t all about the baby’

‘It was really interesting to do’

‘It has made me think’

‘It’s nice to see how well I am doing’

‘I was struggling with my mental health and it showed on the star. The HV and I agreed on the help I felt I needed. After a few weeks she used the star again and we could both see the difference the support I had received had made’

‘I was isolated from my family and desperate to connect with other mums locally and the star highlighted this.The HV then signposted me to local groups, which I found invaluable.’

Accessible data and assessing need

Using the Parent and Baby Star has provided clear data on the needs of families and the impact that HV interventions are having on them. In Warwickshire we run the data analysis every six months to see how things are progressing. Figures 2 and 3 were compiled in October 2021 with the most up-to-date information at that point.

Using the Star readings, we categorised any parents whose readings were three or below (‘Things aren’t okay’, ‘Accepting help’ and ‘Believing and trying’ on the Journey of Change – see Figure 1) as requiring additional support and an intervention was offered. Figure 2 shows the percentage of parents across the health visiting teams who needed support in areas of need across the outcome areas on their Parent and Baby Star.

HVs work with a range of families with a variety of different needs. Figure 3 breaks down those needs in the highest areas of support required and compares them across the health visiting teams.

As can be seen, the needs profile varies across the outcome areas as well as across the county. This indicates the fluctuation in the level of need within the families making contact with the health visiting teams.

Families that required an intervention and support (n=191) had a repeat Parent and Baby Star completed at the end of the intervention to show the change and the impact of that interaction with the HV.

Considering whether parents are making progress through HV support, it can be seen that, across Warwickshire, 80% of parents improved in one outcome area, 58% improved in two or more areas and 37% showed improvements in three areas or more. This indicates that having a HV does improve outcomes for families in Warwickshire.

We used the star and we could see the difference the support I had received had made

What was interesting was the range of effects the teams had in relation to improving outcomes. These are displayed in Figure 4.

This shows that HVs are having a significant impact by decreasing the needs of families they are working with, supporting families at six weeks and then carrying out interventions for those in higher need. Several of the teams showed a 93% improvement in one area of need following support from a HV.

We know that the first 1001 days are critical for brain development and attachment and influence longer-term outcomes in children (HM Government, 2021). HVs can improve these outcomes by up to 93% through carrying out interventions with families; these may include direct work from the health visiting team or appropriate referrals to other agencies. Support with this allows us to show that HVs are improving outcomes for children both now and in the longer term.

Next steps

Health visiting caseloads are complex and ever-changing. To enable us to expand our data capture and understanding of the families we support, we are currently trialling using the Family Star Plus (Burns and McKeith, 2013), another Outcomes Star, with all our child protection and child in need families that require higher levels of assistance and support.

We are also completing a further audit with staff to understand how the Covid-19 pandemic and lockdowns have affected need and the uptake of health visiting services, and to see if there are new barriers to overcome in using Outcomes Stars to provide effective, compassionate and trusted care to our families within Warwickshire.

Sam Game is Outcomes Star and parenting lead for Warwickshire 0 to 5 public health nursing service, South  Warwickshire NHS Foundation Trust.


Burns S, MacKeith J. (2013) The Family Star Plus User Guide and The Family Star Plus: organisation guide. Triangle Consulting: Brighton.

Burns S, MacKeith J, Greaves S. (2018) The Parent and Baby Star user guide. Triangle Consulting: Brighton.

HM Government. (2021) The Best Start for Life. A vision for the first 1001 critical days. The Early years Heathy Development Review report. See: gov.uk/government/publications/the-best-start-for-life-a-vision-for-the-1001-critical-days (accessed 9 June 2022).

Image credit | iStock |Triangle-Consulting-Social-Enterprise-Ltd


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