The following case studies support the Implementation guidance: Perinatal Pelvic Health Services.

Case study 1: South East London – Engagement with diverse groups

South East London PPHS engaged with diverse groups in the local community to increase awareness of pelvic health conditions and offer women knowledge, skills and confidence to manage their pelvic health in the perinatal period.

Joint Strategic Needs Assessments (JSNAs) were reviewed for each borough in the LMNS to identify the make-up of the overall population and the female population by ethnicity and languages spoken. 22 key local groups were identified.

The Lead Pelvic Health Physio and Project Manager ran virtual coffee mornings via Zoom. Open questions were used to understand the groups’ experiences of pelvic floor care. Women that attended were also taught how and when to refer, and how to self-manage their condition. Sessions with the local Latin-American community were run in Spanish and information leaflets were also shared in Spanish.
Findings from these outreach sessions included:

• Some women did not know there were services that offer help
• Some women thought it was normal to be incontinent after childbirth or were embarrassed about their symptoms.
• Many of the women did not know the differences between the roles of healthcare professionals in the UK for example, Midwives versus Health Visitors
• Women did not know that pelvic health physiotherapists can provide care and treatment for pelvic floor issues.
• Women also expressed a desire to have more sessions to discuss other health care topics and like the idea of having consultations in their own communities.

From these community outreach sessions, the team found that building networks in local communities takes time and healthcare professionals need to be prepared to travel to places where communities meet. Collaborating with other groups, even if not within the same geographical footprint, can be useful. It also helps to have health professionals from the same background as the community running the session and, if not, the use of interpreters is vital.

Case study 3: Norfolk and Waveney – Antenatal and postnatal information

Norfolk and Waveney identified inconsistencies in the antenatal and postnatal information provided to women across their three Trusts. The PPHS now ensures that all women using maternity services are signposted to standardised information.

An initial scoping meeting and service user survey was carried out with the local MNVP to guide content. Service users asked for video content and interactive online sessions, as well as a mobile app. Feedback also indicated that patient choice was important, as well as separating antenatal and postnatal information so that women can easily access suitable information at different time points.

A website was developed for pelvic health education and information, as well as the single point of access. The webpages include videos, resources, functionality to book onto monthly pelvic health webinars, and advice on how to self-refer to pelvic health physiotherapy.

A suite of communications resources were also developed, including: postcards signposting how to book appointments; paper leaflets containing pelvic health information; posters and banners for spaces pregnant women visit, such as continuity of carer hubs; and social media templates. Clinical stakeholder meetings and service user focus groups were held prior to launch to gather feedback on the materials.

A free mobile application is also offered to all pregnant women following the dating scan to support them with pelvic floor exercises. The clinical team run antenatal and postnatal pelvic health sessions to help women adhere to pelvic floor exercises, as well as to provide general pelvic health advice. These sessions are held at various community locations including continuity of carer hubs, libraries, and family hubs.

Case study 4: Herefordshire and Worcestershire – Public health campaign

Herefordshire and Worcestershire co-produced a public health campaign and online platform to raise awareness of pelvic floor dysfunction and provide information on how to do pelvic floor exercises.

The campaign was co-produced with the MNVP and focus groups were held to understand what content needed to be included. A website (www.squeezelifthold.co.uk) was developed, which includes information on the pelvic floor, a workout programme, and a monthly blog. Content is added regularly to ensure that it is up to date with evidence-based information. It also includes a tool to translate the content into different languages. Newsletters, social media, and paid advertising have been successfully used to increase traffic to the website. 

Case study 5: Norfolk and Waveney – Self-assessment facilitating self-referral

Perinatal pelvic health self-referral varied across the Norfolk and Waveney LMNS, with only one of the three providers offering self-referral prior to the PPHS.

To plan for the implementation of self-referral and a single point of access across the System, meetings were held with the MNVP, clinical stakeholders, allied health professionals, contracts and commissioning, and the local Just One Norfolk platform led by Children and Young people services.

The LMNS procured the ePAQ-Pelvic Floor Patient Reported Outcome Measure. Women are invited to complete the self-assessment questionnaire antenatally following the dating scan and again four to six months after giving birth. Women receive instant access to their own pelvic floor questionnaire report, and the results are also stored in their maternity records and postnatally on acute Trust health records, and copied to the GP if problems are identified. The results are triaged by a pelvic health physiotherapist who then places women on the following pathways:

• No concerns: Signpost to self-management information on the website and invite to monthly advice sessions
• Mild symptoms: One-to-one advice session with a therapy assistant practitioner and guided use of a mobile application
• Symptoms of pelvic floor dysfunction: Referral to a specialist physiotherapist or, where required, consultant care.

An LMNS-wide standard operating pathway for ePAQ-Pelvic Floor was put in place and is regularly reviewed and updated. ePAQ-Pelvic Floor is also being written into Trust Guidelines (e.g. for bladder care). Clinical review meetings of ePAQ-pelvic floor are held regularly at each Trust.

Since implementing ePAQ, Norfolk and Waveney are seeing an improved rate of identification of sensitive issues such as anal incontinence and referrals are being made earlier in pregnancy, which is enabling more time to treat antenatally. Physiotherapists are asked to complete an evaluation to identify whether referrals via the triage system are appropriate, and so far none have been inappropriate.

Case study 6: South East London – PFE education classes

Standardised face-to-face and virtual antenatal pelvic floor education classes have been implemented across South East London, to offer women support to build the knowledge, skills, and confidence required to manage their own pelvic health in the perinatal period.

An online survey was conducted to understand what content would be useful to service users, and morning coffee sessions were held with community groups. Before launch, maternity staff were invited to attend a drop-in session and information about the classes and other interventions are also shared with midwives on their mandatory pelvic health training.

Women with risk factors for pelvic floor dysfunction (in line with NICE clinical guidelines) are advised to attend the classes and women who do not have symptoms are welcome to attend if they would like to. GPs and Health Visitors are also aware of this service and can advise patients to attend.

The classes last one and a half hours and are delivered online by a pelvic health midwife and/or pelvic health physiotherapist. A minimum of 12 classes a month are available, with one class a week per maternity provider. Some classes are held in the evening. Women book onto classes online and those who attend are sent post-class resources, including links to pelvic health videos and an evaluation survey.

Posters for the classes are available on information boards across providers and there are virtual links to the posters on local perinatal apps. Classes are further publicised via social media and relevant local organisations. Evaluation results have been positive overall, with 85.7% of attendees feeling confident about their knowledge of pelvic floor symptoms and how to find advice and support in their maternity unit and 100% feeling confident on what to do to prevent pelvic floor issues. Further, 89% of participants felt more confident about how to do PFE and 96.4 % reporting that the class has motivated them to practice PFE regularly during pregnancy.

Case study 7: Frimley – Risk assessment tool

Prior to the development of a PPHS in Frimley, few women were referred to pelvic health physiotherapy services perinatally. The PPHS therefore wanted to improve identification of both those with symptoms, but also those that are at risk of developing issues.

The team therefore created a pelvic floor risk assessment tool that enables the pathway to be individualised according to a woman’s risk. The tool also helps to prompt discussion, sharing of information and signposting for all women.

The tool was developed based on a review of evidence for pregnancy and birth related risk factors for pelvic floor dysfunction. Items for inclusion in the tool were discussed and agreed with the steering group, community matrons and midwifery team leads, with sign off via local governance groups.

The tool was initially trialled with one midwifery team and then implementation was phased across providers, with support provided by PPHS leads, including training sessions, resources, and guidance.

The tool is conducted at booking and at 10 days postnatally. A short version is also completed at 28 weeks if a woman begins to experience symptoms. Results are recorded in the new maternity electronic patient record and women receive support accordingly:

• Low risk of pelvic floor dysfunction: directed to resources on the pelvic health website.
• Medium/high risk of pelvic floor dysfunction: offered a group pelvic health workshop led by a Pelvic Health Physiotherapy Associate Practitioner (band 4). Virtual workshops are offered for those who cannot attend in person. Women who do not speak English have the option to view a recording with a family member or to attend an online meeting with a translation function, with advice to direct questions to their midwife at their next appointment where a translator is present.
• Symptoms of pelvic floor dysfunction: one-to-one physiotherapy according to the agreed pathway.

As the assessment takes place at booking, and some women will subsequently experience a miscarriage, a ‘non-pregnancy’ virtual pelvic floor class is also offered for women who have had a miscarriage. Use of the tool has raised awareness of pelvic health among midwives and encouraged better collaboration between physiotherapy and maternity departments. Referral numbers to pelvic health physiotherapy services for pelvic floor dysfunction antenatally and within a year of birth have increased significantly since its introduction.

Case study 8: Birmingham and Solihull – Implementation of the OASI Care Bundle

Birmingham and Solihull have two maternity providers, but the OASI Care Bundle had only been implemented in one prior to the PPHS. To ensure equity across the System footprint, the PPHS worked with the other maternity provider to implement the Care Bundle.

Initially, staff were surveyed on their knowledge and understanding of perineal protection techniques. The perineal specialist midwife also had conversations with staff on perineal protection, which helped them understand staff views and enthusiasm for perineal protection.

The following activities were carried out to support implementation of the OASI Care Bundle:

• An interactive e-learning package on ‘Perineal Protection and Repair’ was created, with videos demonstrating perineal repair and protection techniques.
• Perineal protection displays were put up on the labour ward.
• Electronic notes were updated to include OASI Care Bundle documentation, including an antenatal discussions leaflet.
• OASI Care Bundle education was incorporated into community midwifery pelvic health training sessions.
• The PPHS perineal specialist midwife spent a day on the labour ward each week for staff to drop-in and practice techniques or discuss perineal protection.
• A ‘Spotlight on’ video training series was developed, with each video providing information on a different aspect of perineal protection.
• Facebook posts with information and evidence for perineal protection techniques are regularly shared.

Since implementation of the OASI Care bundle there has been an increase in the use of warm compress in vaginal births from 9% to 50%.

Case study 9: Lancashire and South Cumbria – Implementation of the OASI Care Bundle

Lancashire and South Cumbria wanted to ensure the OASI Care Bundle was implemented across the System to reduce the risk of third- and fourth-degree tears and improve outcomes for pelvic health.

Implementation teams were formed and collaboration was established with the maternity education team. The education team also worked closely with university training providers to support student midwives with OASI training. Throughout implementation, focus groups were held with local MNVPs about plans and the resources. 

All relevant staff were emailed the OASI care bundle manual and there was an OASI Care Bundle ‘learning bus’ to raise awareness pre-launch. Throughout the launch month regular ‘on-the-job’ training sessions were held and OASI badges were given to staff after they had attended training to increase visibility. A train the trainer model was applied, so initially all band 7 midwife coordinators and consultant/mid-grade doctors were trained. In response to feedback that some staff, particularly those working in the community, lacked confidence performing episiotomy and suturing, a multi-disciplinary ‘OASI Care bundle and suturing workshop’ was also developed. The workshops were successful and have therefore been opened to all midwifery staff. A refresher training package facilitated by the maternity education team has been built into maternity mandatory training days and at each departmental induction. 

Case study 10: South East London – Education and training for health care professionals

South East London PPHS undertook a gap analysis across all providers in the LMNS to assess what education was currently available for health professionals on pelvic health care. The analysis found wide variation in the type of training available, the frequency and regularity of training opportunities, who attended and whether training was mandatory. It was subsequently agreed across all providers that a standard package of mandatory Pelvic Health Training needed to be developed for the whole LMNS.

An Education and Learning programme was developed by the PPHS delivery group, which included an obstetrician, urogynaecologist, MNVP chairs, pelvic health physiotherapist, consultant midwife, project manager, and a consultant nurse in urogynaecology.

The group oversaw the development of a mandatory training session for maternity staff and a separate session for Doctors, GPs and Health Visitors. The sessions include the key themes identified from a service user survey, as well as information from services users with lived experience. The content of the training session was peer reviewed by a psychologist who is leading the local Maternal Mental Health Service pilot to ensure that emotional and psychological elements are included.

Mandatory training has now been rolled out across all three maternity providers. The objectives of this mandatory training are for staff to:

• Understand the anatomy and function of the pelvic floor musculature,
• Identify pelvic floor dysfunction and know when to refer to the PPHS,
• Understand the NICE recommendations for the prevention and management of pelvic floor problems,
• Understand the impact of pelvic floor dysfunction in women,
• Teach a basic pelvic floor exercise programme, and
• Provide pelvic health care.

The sessions are 45 minutes to an hour and delivered by a Pelvic Health Midwife or Pelvic Health Physiotherapist twice a month at each of the providers. Where possible, the training is multi-professional. Ad-hoc sessions with Obstetrics and Gynaecology trainees and maternity support workers are also delivered, with a recommendation for them to also complete the pelvic health e-learning module developed by Health Education England (HEE). GP sessions have been organised via GP training Hubs and Health Visitor sessions have been organised with specialist Health Visitor practice educators across all boroughs. These sessions are delivered by the PPHS project manager and the pelvic health physiotherapy lead.

Case study 11: Frimley – Pelvic health champions

Frimley LMNS implemented a new initiative to identify perinatal patients with pelvic floor dysfunction within the wider community workforce.  They provided education awareness sessions for GP’s, Midwives, Mental Health Teams and Health Visitors to increase pelvic health education within the area and awareness of how the PPHS was changing access to perinatal physiotherapy care.

Engagement with GPs was focused on sharing the care pathway and referral system for perinatal mothers to ensure they are referred into the service. Mental Health teams and Health Visitors were offered training on pelvic floor dysfunction, including on identification of symptoms and how to access and refer to the PPHS.

The development of Pelvic Health Champions, who are specifically trained to use the local risk assessment tool and support women with perinatal pelvic floor problems, began within community midwifery teams. This joint working between physiotherapists and midwives in practice has strengthened interprofessional relationships. A pilot team started the initiative which enabled learning on how the process could be successfully embedded across more teams. The service has observed an increase in appropriate perinatal referrals, but not in the significant numbers they were expecting. Empowering other staff to support women has improved awareness of how to access care within a changing system.

Case study 12: Birmingham and Solihull – Staff training

Birmingham and Solihull identified that workforce training in prevention, early recognition and treatment for pelvic health was needed for all health care providers who have contact with women during the perinatal period to ‘Make Every Contact Count’.

A workforce survey was carried out which established several key themes, including that there are a variety of barriers to delivering pelvic health information, which include: time restraints, lack of confidence in the subject, lack of awareness of treatment options, and having other priorities. Many professionals surveyed also did not feel confident in optimising bowel health or best bladder care during labour, birth, and the immediate postnatal period.

It was agreed that the aims of the training should be:

• Prevention, early recognition, and treatment of pelvic health dysfunction in the perinatal period.
• To elicit knowledge about PPHS, new pathways, what resources are available currently and what is being developed.
• Engagement, input, and feedback on the development of the PPHS.

The clinical project team created a multi-disciplinary training package open to all healthcare professionals in contact with women in the perinatal period. It is a two-hour in person or online training which includes practical elements and group discussion and is led by a pelvic health physiotherapist and a specialist perineal trauma midwife. The training is provided in a variety of locations across the System and evaluations are collected to facilitate ongoing improvement.

The training covers: early recognition, prevention, and treatment of pelvic floor dysfunction; PFE; perineal protection and the OASI Care Bundle; the PPHS pathway; and key resources and how to access them. An e-learning on suturing has also been developed by a specialist perineal protection midwife.
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As part of the training strategy, the PPHS also run a session for undergraduate physiotherapy students at a local university, which they are expanding to medics and nurses, master’s students, and other local universities. The training has been well received and supported, with 100% of attendees reporting that they are somewhat or extremely confident discussing how to do PFE with women; 95% are confident discussing perineal protection methods; and 95% are confident in directing women to resources.

Case study 13: Bristol, North Somerset and South Gloucestershire – Midwifery training

Bristol, North Somerset and South Gloucestershire wanted to ensure pelvic health was embedded into routine midwifery care to help break cultural stigmas and beliefs, with a focus on empowerment and prevention of pelvic floor dysfunction, as well as good physiotherapy care. The PPHS project is led clinically by physiotherapists but with a midwifery project manager. It was recognised that many midwives’ knowledge of pelvic health was low, and this needed to be addressed. 

The PPHS carried out midwifery and service user surveys and focus groups to understand:

• What pelvic health knowledge and support service users wanted and in what format and who they wanted it from; and
• What knowledge midwives didn’t have and what their training needs were.

Findings from the surveys were used to develop midwifery training and resources.  It was agreed that it was important to enable and empower midwives to have regular pelvic health discussions with service users and to have the knowledge to give correct first line advice, while not overburdening them.

The midwifery outreach and training programme involves:

• Face-to-face physiotherapy-led midwifery training is provided at both providers. This is a mandatory, bi-annual 30-minute session.
• Midwives were involved in the development of local screening tools. Midwives complete screening with all service users at booking and at 28 weeks in pregnancy.
• Local maternity antenatal care guidelines have been updated to include PPHS screening and discussion.
• Relevant pelvic health requirements have been integrated into the maternity electronic patient record.
• Sessions have been held with community midwives to update, involve, and inform them of PPHS project developments.
• Physiotherapy drop-in sessions on postnatal wards are helping to create multidisciplinary working across midwifery and physiotherapy departments.

Case study 14: North West London – Fully integrated multidisciplinary clinic

Hillingdon Hospital is one of four Trusts that are part of North West London PPHS. One of the elements of the PPHS has been the development of a ‘one-stop’ appointment for mothers with obstetric anal sphincter injuries (OASI).

It was identified that asymptomatic women who had sustained an OASI were not being referred for physiotherapy and therefore not taught PFE. Those with symptoms were referred to the physiotherapy team, however some of the physiotherapists were not fully competent assessing women anorectally and therefore were not assessing the sphincter during appointments.

Hillingdon have therefore set up a weekly interprofessional perinatal outpatient clinic run by a collaborative team made up of a Pelvic Health Physiotherapist and specialist midwife, who are supported by a consultant and registrar. When attending their postnatal consultant appointment, women can jointly see a physiotherapist and consultant on the same day, with a midwife also present to address any other concerns (e.g. lactation or wound care advice).

Collaboration between the specialists within the clinic ensures their knowledge and skills are shared inter-professionally, aligning their skills to the needs of the patient. They provide perinatal assessment and treatments within the clinic tailored to the patient’s needs. As an example, assessments such as detailed pelvic floor muscle assessment is taught to doctors and midwives via the physiotherapist, while the midwife and doctors train the physiotherapist in catheterisation and wound care. This learning environment creates a trusting, open atmosphere for the professionals to manage the most complex cases of wound care and pelvic floor dysfunction following birth.

“our PPHS has provided a really safe space to do follow-up for wounds and develop extended scope specialist skills in a safe, collaborative environment”

As all members are aware of each other’s skills, women in the area are now receiving more timely access to urgent postnatal care by experts.

Evaluations indicate that the service provides patient and staff satisfaction, and the staff feel they can provide the care needed to women in the local area. The team also regularly meet to discuss what went well and not so well and to continuously improve the service.

“This clinic now has become so much more…right there in one appointment we are able to offer a holistic approach to a woman’s body, mental health support, and support her journey through motherhood”

Case study 15: Frimley – Single point of access

Frimley has one acute Trust, with two sites providing maternity care and 9,000 births a year. Prior to the PPHS they had a very low number of referrals to pelvic health physiotherapy services for pelvic floor dysfunction in antenatal or postnatal period.

To improve the consistency of service provision and ensure compliance with NICE guidance, a new pathway was created for referral to the PPHS.  Alongside this, a new telephone triage service for antenatal and postnatal women was launched and included referral to PPHS.

Engagement activities were carried out, including a staff focus group, service user focus group and a survey. These activities revealed variation in where GPs referred women with pelvic floor dysfunction following birth.

The aims, criteria, and pathways were designed with input from Gynaecology, Urogynaecology, PPHS physiotherapy leads and then approved via local clinical governance. This process initiated wider discussions regarding the adult female incontinence pathway.

A landing page, pathway and referral form for the PPHS was developed, with relevant referrals seen by physiotherapists and referred on to Urogynaecology Nurse Specialists or Consultants if required. The launch of this pathway was communicated by the GP communications team and a webinar event was held.

Case study 16: Dorset – Self-referral

Dorset has three Trusts, two maternity units and 7,500 births per year. One site has provided self-referral to antenatal and postnatal women since 2013 and has confidence in this process. The ambition of the PPHS is to move self-referral to a digital format and expand it to women at all three Trusts to:

• Ensure equity across the PPHS footprint;
• Facilitate timely referral;
• Improve the accuracy of triage through improved referral information;
• Offer service users a choice of location to receive physiotherapy treatment;
• Reduce the workload of Midwives and GPs; and
• Reduce urgent phone calls to physiotherapy.

The existing referral form has had nine years of use and staff using it felt confident in the uptake, demand, and opportunities to triage from the data received.  Prior to roll-out to the other areas, the screening questions were reviewed by local pelvic health physiotherapists, midwives and the local MNVP.

Pathways were developed for urgent and routine cases, with possible appointments either as one-to-one or group sessions and either virtual or face-to-face. Physiotherapists also reviewed the format of the received self-referral to ensure it facilitates triage appropriately and enables a ‘RAG’ rating for urgency.

The self-referral form was made available on an LMNS webpage. As this took some time, in the interim digital midwife leads constructed a bespoke form on the maternity electronic patient record for urgent cases. Referrals arrive at an email inbox where an administrator logs them into a department and episode.  Triage is always undertaken by a specialist pelvic health physiotherapist. The administrator then assigns them to an appointment or group depending on the outcome of the triage and sends an appointment letter. The administrator also answers phone calls relating to questions or changes to appointments.

Case study 17: South East London – Collaboration with the MMHS

South East London is ethnically and socially diverse with areas with high levels of deprivation. The LMNS was an Early Implementer PPHS and a Fast Follower Maternal Mental Health Service and the leads for these services identified several common themes between their services, including: the need to understand the local population and gaps in care, coproduction and reducing health inequalities, trauma in the context of maternity, and a focus on prevention as well as access to treatment.

Given these connections, the leads agreed that it would be useful to work together and have been doing so in the following ways:

• Participating in each other’s steering groups and working parties.
• Swapping notes regarding local data (e.g. on physical health, mental health, ethnicity, deprivation, risk factors).
• Sharing resources and relationships (e.g. with psychosexual services).
• Assisting each other with recruitment of staff, which has enabled the recruitment of staff that can treat women holistically, integrating both pelvic health and mental health.
• Facilitating joint awareness events for stakeholders, including an event on holistic wellbeing which was attended equally by healthcare professionals and service users.
• Engaging and educating healthcare professionals and service users, particularly in relation to seldom heard from communities.
• Upskilling both the PPHS and MMHS workforce and increasing training for the wider maternity workforce.
• Developing a clear referral pathway between the services.
• Evaluating women’s experiences of referral pathways.
• Improving data quality together.

Case study 18: Lancashire and South Cumbria – Collaboration with the MMHS

Lancashire and South Cumbria identified early in the PPHS project the opportunity to connect with the local MMHS. Data gathered from the MMHS was used to develop plans for the PPHS, which ensured there was shared learning between the two projects from the offset.  The services have also collaborated in the following ways:

• The leads for each service attend each other’s steering groups which facilitates good communication and opportunities to share lessons learnt and avoid duplication.
• There are regular catch-ups between MMHS and PPHS teams, as well as other organisations such as psychosexual services, health visitors, and the charity sector.
• A joint staff training programme has been put in place.
• The Local Maternity Hub (hosted by the local LMNS) provides a space for MMHS and PPHS to collaborate.
• The local electronic maternity system enables both PPHS and MMHS staff to add notes to a single patient record.
• An informal referral pathway between the services has been put in place to ensure that referral between the two services is as seamless as possible for women.

Case Study 19: North West London – Internal training and development of pelvic health physiotherapists

Imperial College Hospital within North West London has developed an internal training programme for their pelvic health team that facilitates sustainability and succession planning. This development programme helps bring new staff into the service, offers a collaborative approach to shared learning, and enables advanced practice development within perinatal services.

Rotational perinatal posts within pelvic health are provided in both inpatient and outpatient services. A range of rotational roles have been established, including a band 5 rotation, a band 6 pelvic health rotation or a split musculoskeletal/pelvic health rotation.  These offer an introduction to perinatal services, an opportunity for training, and allow rehabilitative care to be provided along the whole perinatal patient pathway.  Those training within these roles typically apply for permanent roles in pelvic health.

“We’ve got one rotational band 5. This rotational post is the reason why we’re constantly able to recruit into band 6 pelvic health roles. We have a lot of band 5s who come, enjoy pelvic health and want to progress further, when the opportunities arise, they apply for band 6 roles.”

Band 5 and 6 physiotherapists are supported to learn enhanced clinical practice within pelvic health. There is an in-service training that the team complete together to discuss complex patients and learn new practical skills, in addition to the completion of competencies that standardise the quality of care and service provided.

“If rotational staff want to do pelvic floor, we’re really supportive and we’ll get them trained up as soon as they start with us.  We complete in-house competencies, which provides standardisation across our team and allows the band 7’s to teach others their skills”.

For the more advanced staff within the service, physiotherapists are supported to complete master’s modules and develop advanced practice skills. The team have several trainee prescribers and physiotherapists within point of care ultrasound, in addition to those with additional pelvic health skills such as utilisation of vaginal pessaries, rectal irrigation and biofeedback.  The service has also utilised the NHS advanced practice apprenticeship to support the development of the staff. The service provides an internal, supportive training environment for entry level physiotherapists and supports the development of advanced practice to enable physiotherapists to provide high quality care to patients, as well as to share their knowledge to train and develop the team.

Case study 20: Frimley – Physiotherapy assistant practitioner hybrid role

To improve consistency in service provision and ensure compliance with NICE guidance at Frimley, a new pathway was created for referral to the PPHS. Alongside this pathway, a telephone triage service for antenatal and postnatal women was launched that enables referral into the PPHS.

Frimley created two Band 4 Physiotherapy Assistant Practitioner hybrid roles with maternity, which are both community and ward based. The Band 4’s work on the postnatal ward and offer initial advice to inpatients after OASI, rectus abdominis diastasis, over distension injury, Pelvic Girdle Pain, as well as advice to women with risk factors for developing pelvic floor dysfunction such as forceps birth, shoulder dystocia, baby over 4kg, twins, and maternal age of over 35 at first birth. The ward staff have found it beneficial to have a consistent ‘specialist’ team member present.

They additionally run perinatal workshops virtually and in-person on pelvic health and anatomy, and prevention and treatment strategies. They have attended a course in perinatal Pilates and now see any one-to-one patient referred by a pelvic health team member. The Physiotherapy Assistant Practitioners also assist with administrative responsibilities such as data collection, booking patients, documentation, and technical support. This has alleviated pressure on other staff members.

Case study 21: Norfolk and Waveney – Band 4 therapy assistant practitioners

Perinatal pelvic health care provision varied across the three trusts in Norfolk and Waveney, so one of the aims of the PPHS was to provide greater consistency of care to service users across the LMNS. To help build capacity across the footprint, a new band 4 Therapy Assistant Practitioner (TAP) role was created.

TAPs go through extensive training before being signed off to work within the service. Their responsibilities in the PPHS include:

• Assisting with the screening questionnaire, including triaging referrals and bookings,
• Running pelvic health advice sessions
• Providing one-to-one support sessions for those with mild symptoms or those who are at risk of problems,
• Monitoring use of the mobile application that which is provided to every pregnant woman,
• Handing out surveys, and
• Collating data, including service user feedback.

Norfolk and Waveney have found that TAPs have fitted into the service well. Trusts with Continuity of Carer in place have had a better uptake of care and this is thought to be due to TAPs being present in maternity hubs.

Case study 22: Dorset – Physiotherapy leadership

Dorset has recruited a band 8a pelvic health clinical lead who has supported the development of the PPHS but also manages the overarching pelvic health physiotherapy team. This has worked well in this rural area, because it has helped ensure the sustainability of the service by facilitating the development a larger workforce and appropriate training for all within perinatal and pelvic health services.

“We have a workforce of lots of part-time staff, and I know how important it is that in the end all staff can do almost everything in pelvic health, so we have resilience when somebody is off sick, and knowledge across the team”.

In a rural area that has smaller numbers of perinatal patients that are widely spread out, this model is beneficial, as it has enabled the smaller allocation of funding for perinatal care to be embedded within the larger pelvic health service by spreading the education and patient allocation amongst all staff. The pelvic health lead prioritised and provided training within the wider perinatal service in addition to the pelvic health service.

At an 8a staffing level, the leader can escalate the appropriate learning needs for their team, rather than their specialist needs sitting under a musculoskeletal physiotherapy service, where the allocation of training is unsuitable for the pelvic health service.

A flexible recruitment strategy implemented by the pelvic health lead ensured that support and training to enter the pelvic health workforce was provided. This was done by highlighting experience as desirable rather than necessary within pelvic health. This is different from other areas that would always ensure that high amounts of experience are necessary to apply for a band 6 and 7 role. The experienced pelvic health leader is aware of the service’s needs as well as the training needs of the team, so that they are able to make strategic decisions that support the management of services in addition to the recruitment and sustainability of the workforce.