How the Family Nurse Partnership is adapting its work after criticisms

The Family Nurse Partnership (FNP) was first piloted 10 years ago in the UK, after being used successfully in the US since the 1970s.

The established model of FNP consists of a programme of structured home visits for vulnerable, first-time teenage mothers from early pregnancy until their child turns two, with support focused on addressing their health, social care, education and employment needs.

FNP is backed by a strong body of evidence from the US that shows benefits for family health, reductions in neglect and improvements in parental income.

Encouraged by its findings, the government in 2013 pumped millions of pounds into extending FNP's reach. But in October 2015, a study published in medical journal The Lancet questioned the UK programme's effectiveness.

Research by the Cardiff University School of Medicine found similar rates of smoking during pregnancy and second pregnancies - both primary measures - in a trial of FNP and control groups. In addition, rates of child safeguarding concerns and child hospital emergency admissions were higher in the FNP group.

The Cardiff study concluded that FNP was not cost-effective on the primary outcomes, but that any changes to the intervention could justify this being reassessed.

Ailsa Swarbrick, FNP national unit director, admits the study findings were "difficult", but that they added fresh impetus to work to further develop the programme in the UK.

"We would have preferred the results to be different, but we've tried to think about how we could learn from this," Swarbrick says.

Adapting the programme

She also says the study did not completely reflect how the programme was being adapted and used by councils to address child maltreatment and development.

"It was commissioned by the Department of Health a while earlier, and the outcomes selected strongly reflect that health focus," she says. "We were moving into a phase when FNP was going to be commissioned by local authorities.

"The programme was brought from the US and the trial found we were delivering it well. But we knew we had to make changes and put into a UK context better."

For Swarbrick, the "intriguing" finding from the trial was the positive impact FNP was having on emotional dimensions of child development. Although not a primary measure of the study, there was recognition of the programme's benefits on relationship quality, child cognitive development, language development and maternal mental wellbeing.

Swarbrick says that over the past year, work has focused on finding out from commissioners what aspects of the programme are useful in improving child development and safeguarding.

"We consulted supervisors and commissioners all over the country and asked what they valued," she says. "We took a step back about where we go from here, and what the evidence is telling us and what customers want."

Councils said they wanted greater flexibility in how the programme was implemented so that it was shaped around local needs. But Swarbrick says this posed a challenge for the national unit as FNP is a licensed programme.

"There's a balance between not moving too far from the evidence base and, at the same time, fine tuning it and matching it to the needs of populations and areas," she says.

Workshops with commissioners identified four key outcomes on which they wanted the programme to focus: child development, safeguarding, perinatal mental health and maternal health.

Other important considerations included value for money and the ability to share best practice.

Next steps

On the back of the consultations, the national unit has developed a four-part change programme, FNP: Next Steps, which it hopes will cement FNP's future.

The main element is a series of improvements to the universal offer.

Eligibility criteria for involvement in FNP has been extended from 19 to 24, and it will be available to mothers with vulnerabilities other than teenage pregnancy.

Smoking cessation and nutrition guidance for nurses has also been updated; and new data collection tools have been introduced to improve the amount of data captured and how it is used to evaluate impact. Nurses input data on client characteristics, delivery elements - such as number of visits - and short-term outcomes.

Data is viewed at site level and nurses can use it to improve prevention work, says Swarbrick.

A knowledge and skills exchange has been developed which will be used by FNP sites to spread best practice and intelligence garnered from the programme to professionals in other children and family services. Learning packages include the impact of attachment, and the teenage brain, she explains.

"On attachment, we know it builds resilience so children are better ready to learn," she says. "It's about how you intervene early with those problems that may already be manifesting themselves when a child arrives at school. How do you get a child school-ready? In the US, school readiness is much higher in FNP children.

"What we're picking up is that nurses are often being asked by their local providers to do training in how [assessment] tools may be used by others. Nurses have been able to get a good level of engagement with families who are often reluctant to use services. Much of that is about a respectful approach and integrating that into their practice - so a chat about child development becomes part of their work and not just a test."

The final part of the FNP Next Steps jigsaw is the creation of 11 pilots that will collaborate with the national unit to design and test adaptations to the overall programme on a range of complex clinical and social interventions.

New approaches

Throughout 2017, the Adapt sites will test new approaches to smoking cessation, raising breast-feeding rates, tackling domestic violence, childhood attachment and safeguarding.  

"We wanted to do it in a collaborative way rather than top down," says Swarbrick. "We've worked with nurses, providers, commissioners and service users at the sites. We wanted to be led by the things they thought were important.

"We also had to be pragmatic and do something quickly - we don't have time to do a randomised controlled trial. It's about the balance between having good enough evidence and going with what we thought would work."

She says all the pilot sites will be testing approaches to personalisation. "In that adaptation, we're looking at testing changes to eligibility, flexing the content more than the current programme; reducing numbers of visits; and allowing clients to leave early," explains Swarbrick.

"The purpose is to improve outcomes, value for money and local responsiveness."

Swarbrick accepts the approaches developed by the pilots are not perfect - "they are probably 60 per cent there" - but will be assessed every three months and adapted further depending on results.

"Part of this is about being open to things not working," she says. "We want to test the outcomes they produce, look at client and nurse experience and the implementation. For example, does a pathway work and can you make the right referrals; what are the implications for workloads; can you bring in other services to support the aim?"

Swarbrick says the aim is to improve outcomes, but is "hoping some things don't work".

"That sounds negative, but you have to rule some things out," she adds. "We'll have clear ideas about things that are working well across sites, some we'll want to test further and some that won't work."

Swarbrick says that Adapt and the rest of FNP: Next Steps is about "building on the foundations" of the licensed programme. She expects the work will result in a different core FNP programme within two years.

Cost effectiveness is also crucial and the national unit is keen to show that FNP delivers a return on investment through supporting early help across health and care services for children and families, and saving money "further down the line - whether from foster care, schools or health outcomes".

Changes being introduced could make FNP more cost-effective by increasing the number of people going through the programme; sharing knowledge and skills derived from interventions more widely; and doing more work with wider family members.

The key to the changes being a success is to get the balance right between a consistent core FNP offer and local flexibility, she says.

"Having a consistently delivered national programme with consistent guidance and training is sensible, as is understanding how sites can flex and improve locally.

"It's about finding that sweet spot between bottom up and top down where you get the best of both. That would be the ideal - but I'm not saying it is easy."


Dudley adapts programme to encourage more young mothers to quit smoking

In Dudley, smoking rates are higher than the national average, with 15.7 per cent of women saying they smoked at the time of their baby's delivery compared to the national average of 11.4 per cent.

Dudley is one of 11 ‘Adapt' pilot sites testing new approaches. Ceri Evans, Dudley FNP supervisor at Black Country Partnership NHS Trust, says this will allow it to try out adaptations to the FNP programme around smoking cessation.

"The main prize is reducing the number of young mums smoking in pregnancy," she says. "Our development work pointed to the influence of family and friends on whether a young mum quits, and encouraging those around the pregnant woman to stop smoking is a secondary outcome we're hoping to achieve.

"Some of what we're implementing draws on tried and tested methods used elsewhere. Family nurses will use carbon monoxide monitors, as local midwives do, and they will be able to prescribe nicotine replacement therapy to pregnant women and their partners. We'll also use new resources such as silicone foetuses, apps and YouTube clips to convey messaging about how smoking can affect a baby's health."

Evans says that consultation with existing FNP clients has helped it incorporate young mums' perspectives into the approach.

"Many told us they valued the opportunity to have an upfront conversation about smoking in pregnancy with a trusted professional," she says. "With new pathways in place, training done and materials ready to go, we began rolling out our revised FNP programme in Dudley in December."


Guide to FNP