Overview

1. Research and the application of evidence within the work on Family Nurse PartnershipsAlice Wiseman, Children’s Commissioner Lead, South TynesideDave Webber, Service Development Lead,FNP, Department of Health

2. Overview • What is FNP and how does it work? • FNP in the UK • Evidence from US and England • Effective Replication • Implementation of the FNP at a local level

3. What is the Family Nurse Partnership? • FNP is an evidenced based, preventive, early intervention programme for vulnerable young first time mothers and their families. • It offers intensive and structured home visiting, delivered by specially trained nurses, from early pregnancy until age two. • The programme developed in the US over 30 years. Three RCT’s undertaken with follow up. • Testing in England began in 2007

4. How Does FNP work? • Family nurses build supportive relationships with families and guide first-time teenage parents. • Nurses use behaviour change methods so that young parents adopt healthier lifestyles for themselves and their babies, provide good care for their babies and plan their futures. • The programme uses in-depth methods and tools to work with young parents on attachment, relationships and psychological preparation for parenthood helping them to overcome adverse life experiences

5. Testing FNP in England Small scale testing 07-10 10 wave 1 sites Large scale testing 08-11 40+ sites in 5 ‘waves’ Measured Expansion 2011-15 Evaluation 07/08 to 10/11 Sharing the learning RCT 2b and wave1 Testing: Programme delivery, training, organisational and service context, workforce, commissioning, eligibility, recruitment pathways, roll out

6. FNP in North East • Current Sites • Co Durham and Darlington • 1 Supervisor and 6 nurses • Expanding with additional supervisor and 6 nurses • South of Tyne and Wear • 1 Supervisor and 8 nurses (4 in RCT Sunderland) • Expanding with additional supervisor and 6 nurses • New Sites (Starting January 2012) • South Tees • 1 supervisor and 4 nurses • North Tees • 1 supervisor and 4 nurses

7. High Quality Evidence Base • 3 large scale randomised control trials (rcts) with long term follow up which tested the programme with different populations in different contexts • 3rd trial tested delivery by para-professionals compared to nurses • Programme enhanced and retested following results from each trial • Only where positive impacts consistent in at least two of the three trials confident to say “programme achieves x,y,z” and ready to offer for wider replication as a licensed programme. • Consistent results showing benefits across a wide range of outcomes for both mother and child over short, medium and long term • NFP consistently rated having highest standard of evidence by independent reviews of effectiveness e.g. Blueprints, WSIPP, Coalition for Evidence Based Policy

8. FNP has consistent results in outcomes across 3 scientific trials in USA Improvements in women’s antenatal health and behaviours Reductions in children’s injuries, child abuse and neglect Fewer subsequent pregnancies Greater intervals between births Increases in fathers’ involvement Increases in maternal employment Reductions in welfare dependency Better parenting Improves children’s cognitive development, school readiness and academic achievement Improves children’s emotional and behavioural development Reduces children’s involvement in crime and anti-social behaviour later in life Reduced substance use initiation Substantial cost savings – up to $5 for every $1 invested by age 15

9. Building the English Evidence Base 4 main strands: • Formative Evaluation in Wave 1 Pilot Sites – Can FNP be Implemented with fidelity in England and does it have the potential for positive impacts? • Randomised Control Trial (Wave 1 and 2b sites) – Does FNP benefit young mothers and their children over and above usual services and how cost effective is it? • FNP Monitoring Information – Is FNP being delivered with fidelity to the programme model? What are the characteristics of those receiving FNP? • Development projects – focussed research on specific aspects of programme delivery and implementation to inform programme development and improvement.

10. Evaluation in England • High quality replication of the programme • 87% enrolment, fathers engaged and low rates of attrition • There are early signs that clients now have aspirations for the future and cope better with pregnancy, labour and parenthood • Reduction in smoking during pregnancy • Breast feeding initiation rate higher than national rate for same age group • Significantly improved mastery, a form of self esteem linked to positive behaviour change, at the end of the programme compared to the start. • Clients were returning to education and employment, making regular use of effective birth control methods and spacing subsequent pregnancies. • FNP children also appear to be developing in line with the population in general which is very promising as this group usually fare much worse. • Graduates of the programme very positive about their parenting capability reporting high levels of warm parenting, low levels of harsh discipline and levels of parenting stress similar to that in the normal population.

11. Evidence in England (1) FNP can be delivered well in England • Programme can be delivered with fidelity to the US model. • Successfully engages with hard to reach families from early in their pregnancy - 87% of women offered programme enrol, • Retention of clients in the programme was good. • The materials work in this country and are well received by families. • Clients like and value the programme and have high regard for their family nurses. • Engagement with fathers is good. Almost half the fathers and partners had been present for at least one FNP visit. • Family nurses are highly satisfied with their roles especially as they have become more experienced in delivering the programme The programme has the enthusiastic support of the nurses who are seeing changes take place in health behaviour, relationships, parental role and maternal well-being.

12. Evidence in England (2) Families like FNP and think it is making a difference • Many clients reported positive changes in their understanding of pregnancy, labour, delivery and their infant • Clients more confident as parents, doing activities with children likely to enhance cognitive and social development • Closer involvement of fathers with infants • Feel less judged and excluded, thinking about the future with more optimism, gives them an expectation that services could be helpful • Fathers remained involved in the programme through toddlerhood, many getting more involved as they enjoyed play and other activities with children. • Family nurses see clients as empowered, confident and making good life choices.

13. Evidence in England (3) Potential for impacts is good • There are early signs that clients now have aspirations for the future and cope better with pregnancy, labour and parenthood • Reduction in smoking during pregnancy - 40% to 32% (20% relative red.) • Breast feeding initiation rate higher than national rate for same age group (FNP = 63% UK under 20s=53% ) • They also had significantly improved mastery, a form of self esteem linked to positive behaviour change, at the end of the programme compared to the start. • Clients were returning to education and employment, making regular use of effective birth control methods and spacing subsequent pregnancies. • FNP children also appear to be developing in line with the population in general which is very promising as this group usually fare much worse. • Graduates of the programme very positive about their parenting capability reporting high levels of warm parenting, low levels of harsh discipline and levels of parenting stress similar to that in the normal population.

14. FNP RCT in England • DH have commissioned an independent RCT to assess effectiveness of FNP compared to universal services including its cost effectiveness. • Being undertaken by South East Wales Trials Unit, Cardiff University, Professor Michael Robling is principal investigator • Began 2009, due to report first findings end of 2013 based on following families to children reaching 24 months • 1645 participants across 18 sites, individually randomised • Focussing on three outcome domains: • Pregnancy and birth • Child health and development • Maternal life course and self sufficiency • Just the start, plan is to follow up families over the longer term as know from US many of FNP’s favourable outcomes come later as child gets older

15. Effective Replication • Evidenced based programmes must be replicated in line with the original research model if the intended outcomes are to be achieved • NFP one of only a few programmes effectively replicated to scale What is important in replication • Targeted on those populations shown to benefit • Engagement – engaging the right people, at the right time and keeping the programme participants engaged throughout programme duration • Dosage – getting the amount of the intervention intended • Content – delivering the planned programme content • Skills of those delivering intervention –the skills of those delivering the programme should be consistent with those in original research and that skill level should be maintained. • Ensuring these through supervision, monitoring and evaluation

16. Replicating FNP in England – what we’ve learnt about replication in the real world (1) • Can deliver programme well, but considerable variation between sites – need to understand this more • Effective replication helped by licensed programme with measures to ensure fidelity to the programme model (core model elements) • Taking it slowly with formal phases – preparation, learning, small scale permanence to large scale permanence • Role of FNP National Unit as license holder in England • The importance of commitment - clients, nurses, organisations • The role of the supervisor as custodian of quality and replication • Organisational support matters • Replication has to focus on the how as well as the what and when • Need an understanding of research and confidence in the programme • Learning programme that imparts competence, confidence and courage • From novice to expert

17. Replicating FNP in England – what we’ve learnt about replication in the real world (2) • Fidelity measures secure what can be secured, but most depends on the motivation of the family nurses and the impacts they see • Role of database • The rest of the world is not fixed • Role of clients in fidelity reinforcement • The role of the system in helping or hindering replication • Research trial • Sharing the learning - spin-offs to increase coverage • Recognising that the whole is more than the sum of its parts

18. Learning to improve delivery • Both practice and systems • Organisational readiness – culture, behaviours, systems, commitment • Supervision and the supervisor role • Engagement, agenda matching • Quality assurance systems • Safeguarding and child protection • Local integration – Sure Start Children’s Centres, health visiting and social care • Some aspects of the programme e.g. fathers, second children, new partners, • Effective scaling, replication and fidelity • DANCE

19. Sharing the learning • Preparation for Birth and Beyond • PREview • HCP E learning • Model of practice for HV • HV Early Implementer sites • Group FNP

20. Implementation of the Family Nurse Partnership at a local level NHS South of Tyne and Wear Alice Wiseman – Children’s Commissioning Lead – South Tyneside

21. Overview • Translation over the Atlantic • Strategic Implementation • Engagement with partners • Commissioning in times of austerity

22. Translation over the Atlantic • Evidence based programme from the US • Ensuring programme fidelity • Application in the UK context: • Different organisational arrangements • Different health and social care provision • Different levels of need

23. Strategic Implementation • Ensuring fit with organisational priorities • Maternity Integrated Strategic and Operational Plan • Children and Young People’s Plan • Linking with key partners • PCT • Children’s Trust arrangements • Reporting arrangements

24. Engagement with partners • Change management (in a time of change) • Different organisational cultures • Integration with children’s services without jeopardising programme fidelity • Changing organisational arrangements

25. Practical Implementation • Recruitment – Pressure of HV Early Implementation Sites • Skill mix • Opportunities to share the learning?

26. Commissioning in times of austerity • Commitment to the programme – 2/3 year duration • Impact organisational changes – wider partners (e.g. children’s centres) • Demonstrate impact and value for money

27. Further information For further information and queries contact: familynursepartnership@dh.gsi.gov.uk To find out more about the programme http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_123238