Young mums see rosy future

It has been rigorously tested, tweaked and extended across the US. Now the Family Nurse Partnership (FNP) programme, backed by a strong body of evidence, is to become a regular fixture over here. The scheme, which consists of a programme of structured home visits, targets vulnerable, first-time teenage mothers from early pregnancy until their child turns two. Support is focused on addressing their health, social care, education and employment needs.

Family nurse partnerships were first piloted in England in 2007. Evaluation of randomised control trials in the US demonstrated their impact, while emerging evidence from domestic trials has also shown improvements in family life. So the government has announced plans to expand the programme. Eleven thousand families have thus far been supported and at the start of April, health minister Dan Poulter announced a further 5,000 would be helped as part of a £17.5m funding package.

A three-strong consortium is charged with supporting training, research and expansion. Tavistock and Portman NHS Foundation Trust, a specialist training mental health trust, will advise on training issues and manage the Family Nurse Partnership National Unit, which supports local FNPs. The Social Research Unit at Dartington will oversee evaluation. And Impetus Trust, an ethical investment charity, is offering commissioning and strategic advice to local areas wanting to set up a family nurse partnership.

There are FNPs in 91 areas across England, located particularly in areas of high social deprivation and high teenage pregnancy rates. The bulk of the new funding will support training places.

Rita Harris, director of child and adolescent mental health services at Tavistock and Portman NHS Foundation Trust, says: “Our aim is to look at ways in which, ultimately, it can be rolled out everywhere.”

Under the terms of its US licence, all family nurses must be registered with the Nursing and Midwifery Council. The work is based on structured home visits (see “How the Programme Works”, opposite). According to research published this year by the Institute for Employment Studies (IES), the majority of family nurses are former health visitors, midwives and school nurses. Most are also experienced nurses, with three-fifths over the age of 50.

Chris Tully is chief executive of Ripplez, a nurse-led community interest company formed in 2011 that offers the FNP programme in Derbyshire, the city of Derby and Burton-on-Trent. She says it is important that qualified nurses rather than social workers or other children’s professionals deliver the programme.

Tully says: “When they were testing it in the US, they tried it with other professionals and found that nurses were trusted more and got better results with the young families.”

She adds that the experience that health visitors and midwives hold in home visiting and supporting mothers with breastfeeding and postnatal depression gives them an advantage. In addition, teenage mothers help the local health trusts and councils recruit the best candidates by sitting on interview panels, says Harris.

Small caseloads are vital to the programme. Under the FNP licence, each family nurse must not have a caseload exceeding 25, a tenth of Unite’s recommended caseload for health visitors, which is far exceeded in many areas. “This limit is necessary to ensure we can get around to see everyone,” says Tully. “It would be very difficult with more. All the support is one-to-one and mostly in their homes.”

There is also a strong focus on supervision. Each FNP has one supervisor to no more than eight family nurses, providing four supervision sessions a month to allow for reflection on the job and address any problems. Supervisors also must have a small caseload of three families to comply with the licence. This ensures they maintain their clinical skills and have a greater empathy with the family nurses.

Anne Lynch, supervisor of Tower Hamlets FNP, one of the first to pilot the initiative in England, says domestic violence is an issue often brought up in supervision sessions. “It is unfortunately something that happens among this young population and it can also have an emotional impact on the nurses”, she says. “Some of these families’ lives are in chaos and that needs to be talked through. It is vital that we support each other.”

Encouragingly, the IES research found high job satisfaction rates among family nurses. Four-fifths said the role met their expectations and they were happy at work, and eight out of 10 said it was better than their previous nursing role. One told researchers: “I do not want to do anything else – this is the best job I’ve ever had.”

However, the research did highlight areas for improvement. In some places, administration support needed to be increased and “IT support – or the lack of it – was also causing problems, especially given the amount of data that needs to be entered”, said the report.

This was contributing to family nurses having to work longer hours, with two out of three nurses and nine out of 10 supervisors saying they regularly worked more than their contracted hours. Concerns were also raised about residential courses, which form part of family nurses’ 15 months of training. Some nurses with children found these a problem to attend. The evaluation noted, however, that this residential aspect of the course was a key part of “the team-building process”.

Lynch says that regular role-playing sessions in training, where nurses take the role of the client, also help build the strength of the family nurse team and empathy with families. Family nurses that spoke to the IES were on the whole impressed with the training, which includes supervised visits to families, motivational interviewing techniques and gaining trust with parents. Engagement with fathers, where appropriate, is also covered.

A key part of the FNP is to build links with local colleges, social work teams and health professionals to take referrals of young mothers-to-be and refer clients on to other specialist support, such as careers guidance professionals.

Links with GPs, social workers and midwives are particularly important to getting referrals to the programme. While many of the young mothers-to-be who are referred are from deprived areas or have complex issues, the programme is open to any pregnant teenager.

Ripplez’s Tully says: “It is important that we have an open-door policy and not base it on their economic circumstance, as we do not want to stigmatise any group.”

Given its longevity and history of randomised control trials, the strongest evidence of FNPs transforming teenage parents’ lives comes from the US. Tully is confident that over time, long-term research in the UK will show similar results: “For example, we have one young mother who is now looking to become a nurse herself. She comes from a workless household and wouldn’t have even thought of this career until she had been on the programme.”

Ripplez also supports a parents’ support group for those who have graduated from the programme. “Another of our mums now runs that group as a volunteer so she can use her experience to help others,” adds Tully.

In his government-commissioned report on early intervention, Labour MP Graham Allen cited family nurse partnerships as one of the principal programmes worthy of significant investment. “In the longer term, the FNP could be established as a core early intervention programme for vulnerable first-time young mothers in this country alongside universal health visiting,” he said.

Given its emerging success in the UK, could FNPs be enlarged to involve support for a wider group of vulnerable families, those with mental health issues or disabilities for example? Dave Munday, professional officer at Unite, says this is highly unlikely: “This evaluation shows success, but only if you use this exact group of professionals with this exact client group, offering this exact structure of programme. If you change one element, then the evaluation is no longer valid and you will have to create a completely different programme.”


HOW THE PROGRAMME WORKS

All family nurse partnerships in the UK operate under licence from the US programme called Nurse Family Partnership.

Those looking to run the programme have to adhere to its timetable of support and offer one-to-one help for families from the same nurse for the duration of the programme.

The timetable for support under this licenced programme is structured so that extra help is available at key moments in a young mother’s life, including just after her baby is born.

Only first-time mothers-to-be, who are under the age of 19 at the time of conception, are offered a family nurse. The programme is offered only to those who are less than 28 weeks pregnant, and ideally when they are 16 weeks pregnant.

Anne Lynch, nurse supervisor at Tower Hamlets FNP, says: “Offering support from during, rather than after, pregnancy is important. Evidence from America proves that is a key time for nurses to build relationships with a family.”

The first month of visits during pregnancy are weekly, to help build trust between nurse and family. They then drop to a visit every two weeks until the baby is born and become weekly again for the first six weeks after birth. This increase in visits is to help with specific challenges facing young mothers, such as postnatal depression and breastfeeding. After this time the visits drop to every two weeks and then when the baby is 18 months old, they become monthly. Each visit is around an hour long and they take place until the child is two years old.

The support that is offered while the baby is a toddler often focuses on help with employment and education opportunities through referrals to local colleges.
 
Lynch adds: “It is important that we do not promote dependency. The support we give is driven by the mother. We want them to be independent by the time we leave them.”

Visits throughout the programme cover issues such as housing, education, diet, contraception and parenting skills.

They also set out to focus on the “strengths” of the mother rather than the deficiencies, says Lynch. “What you do not want is a nurse going in and criticising them. That will get us nowhere”.

For more information, visit www.nursefamilypartnership.org


THE EVIDENCE

The US-based organisation Nurse Family Partnership licences Family Nurse Partnerships globally.

It has carried out research since the 1970s involving three trials in Elmira, New York, since 1977; Memphis, Tennessee, since 1988; and Denver, Colorado, since 1994. Each has compared the outcomes for FNP families with a control group of families from similar backgrounds.

Birkbeck College, University of London, carried out the UK evaluation and has studied the programme’s implementation in England since 2007. Its latest report was released in August 2012.

Does FNP improve family health?
Twelve-year-olds who had been part of an FNP as an infant were less likely to smoke cigarettes, drink alcohol, take cannabis or have mental health issues than those from a comparison group, according to 2010 research from the Memphis trial. They also scored higher than the control group in reading and maths tests during their first six years of education.

Birkbeck’s analysis of the programme in England found a reduction in smoking among mothers taking part, from 40 per cent in early pregnancy to 32 per cent at 36 weeks into the pregnancy. Less than two thirds of mothers (63 per cent) supported by an FNP breast fed, while 36 per cent were still breastfeeding at six weeks.

Does it reduce child abuse and neglect?
Research on the trials in Elmira from 1997 found a 48 per cent reduction in cases of child abuse and neglect among families supported by an FNP by the time their first child was aged 15. Emergency hospital visits due to injuries were halved during the child’s second year of life among those visited by a family nurse, according to research on trials in the same area in 1986.

Children in a controlled group in the Memphis trial were four-and-a-half times more likely to die in their first nine years than those who had been part of the FNP, according to evidence published in 2007.

Does FNP improve employment opportunities for mothers?
Families visited by a family nurse received £8,000 less government support than families in a control group by the time their first child was 12, according to data published in 2010 from the Memphis trial. Mothers in the same trial area were twice as likely to be in work than those in the control group by the time their first child was two years old, according to research published in 1997.

Does it save taxpayers money?
The cost per child of an FNP intervention was £5,800, but it saved US taxpayers £11,000 over the first 15 years of the child’s life, according to research on the Elmira trial released in 2004. A further study of the same trial area two years later offered more detail and found that crime reduction was the main saving.

In England, Birkbeck’s evaluation of the second year of the pilot found that the cost per client is around £3,000 a year. In the UK, the researchers noted that this equates to the cost of around six weeks of foster care.

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