8 IMPLEMENTATION OF FNP IN SCOTLAND
Among the key aims of the evaluation as set out in the research brief are:
· to identify factors that support or inhibit the delivery of the programme, and
· to report family nurse, client and programme management views and experiences of the programme.
It is largely a process evaluation, with an emphasis placed on evaluating the implementation of the programme in Scotland and understanding how it works in a Scottish context.
This chapter describes the early implementation of the programme, drawing largely on the perspectives of key informants within Scottish Government, NHS Lothian (including members of the FNP implementation team), City of Edinburgh Council and the DHFNP National Unit, England. Key informants held a mix of high-level, strategic posts and implementation roles in relation to FNP. Interviews explored their perceptions of the funding, management and organisational structures and perceptions of the factors that had either facilitated or impeded the implementation process (from their perspective). The focus, therefore, is on the infrastructure of the programme as it was implemented in the first test site in Scotland in order to distil any implications should the programme be rolled out to other areas.
8.1 The funding model
The funding model for the Edinburgh site is different from the mechanisms in place in England, where sites are only wholly DHFNP National Unit funded if they are part of the RCT. The other sites are funded locally, with a central DH part-funding contribution in the first year, some jointly funded by Primary Care Trust and local authority. The decision to part fund was based, partly on the basis that full government funding might inhibit local ownership and sustainability of the programme.
We took the view from the beginning that we would only half fund the first year because if Government funds something altogether, by the time it ends … when it ends, they won't pick up funding locally, and there isn't that sense of ownership, and these are their vulnerable babies.
The decision by the Scottish Government to fully fund the Edinburgh programme was based on the uncertainty in the current economic climate and the potential risk posed by this for the programme to be completed in its entirety..
8.2 The links with the National Unit at the Department of Health, England
FNP cannot be delivered without a licence from the University of Colorado, Denver ( UCD) where David Olds, the programme's developer and Professor of Paediatrics, Psychiatry and Preventive Medicine is based. There is a licensing agreement between Scottish Government and UCD and a consultancy agreement (in the form of a Memorandum of Understanding) between DHFNP National Unit and the Scottish Government for the DHFNP National Unit to provide training and consultancy support: 23
It operates (…) reasonably formally at one level in that [ DHFNP National Unit] is responsible for training and providing the materials, sharing learning, providing advice as needed, and that's essentially ... that's what [ DHFNP National Unit] do.
In addition, the National Implementation Lead for Scotland has been able to undergo all FNP training that both Family Nurses and Family Nurse Supervisors undertake. This was described this as a quid pro quo arrangement which has allowed a member of the Scottish Government FNP team to 'immerse ' themselves totally into the FNP education programme via the process of experiential learning and, where appropriate, to contribute to the UKFNP training programme delivery including facilitation of FNP 'Learn and Change' sets.
The relationship with the DHFNP National Unit was seen as crucial in a number of respects. First, it was acknowledged that the English RCT will provide the evidence relating to outcomes and that this, in turn, allows the Scottish Government to focus on local implementation processes. Second, the learning that has accumulated in England is being shared with Scotland and, at a strategic and operational level, is seen as invaluable. Third, the training that the Family Nurses and the Supervisor undertake is largely provided by the DHFNP National Unit. Not only does this provide very "high quality training" for the team, but also ensures that the Family Nurses (and the Supervisor) can be part of wider groups with whom they can share experiences and learning. This was deemed by Nurses and other stakeholders to be of great value to the programme in Scotland.
Well I think there is absolutely no way we could have done it without the Department of Health. Nobody to my knowledge in Scotland has the experience of the Family Nurse Partnership because it hasn't ever been tested here.
It was notable that the consultancy agreement was a new model for FNP, since UCD ordinarily provides the consultancy support. The Licensing agreement with UCD was also a new arrangement to both the DHFNP National Unit and the Scottish Government. In the absence of such a precedent, it remains to be seen whether the form of the current consultancy arrangement between DHFNP National Unit and the Scottish Government has been the most productive mechanism for supporting implementation. Specifically, concerns were raised that distances from London can inhibit meaningful participation with the National Unit at the DHFNP National Unit. It was also suggested that a more clear-cut financial exchange might have been useful and beneficial for both parties for which their costs are reimbursed after training and consultancy support. Moreover, if there are to be more sites in Scotland (and indeed, at this point in time, the programme is due to commence operation in NHS Tayside and plans have been announced to begin looking at FNP extension in NHS Greater Glasgow & Clyde region) a position may ultimately be reached where consideration might be given to the feasibility of developing FNP consultancy and training expertise within Scotland.
I think …we have got to make a decision in the future, if this is a programme that's extended anywhere else, do we develop a home grown Family Nurse Partnership Central Team in Scotland?
I think in the long term, we need to think through ... what it would look like. You know, if Scotland goes for 10 sites, what would that then look like in terms of who's going to do what [ DHFNP National Unit] do - a national unit - because you do need a national unit doing this ... doing what [ DHFNP National Unit ] do really.
8.3 Management and governance
Management and governance were raised spontaneously by stakeholder informants (in every setting) as issues that they felt had impacted on ease of programme implementation.
The FNP National Project Board meets once every three months and includes representation of the key agencies. The National Board was described as providing an "overarching perspective" and is intended to be the vehicle for ensuring that the various arms of the programme can be co-ordinated. There is also a small NHS Lothian Steering Group and a larger multi-agency Edinburgh CHP group that focuses on operational issues and does not include government representatives.
There is a clear line management and professional supervision structure within NHS Lothian for programme delivery. However, there was a perception among stakeholders that management roles can - at times - become blurred between sectors and that this can affect the ease of implementation of the programme. Both strategic and operational stakeholders suggested that the number and the relatively high status of those involved in the Edinburgh site had led to management structures that appeared to them top-heavy - described by one stakeholder as "a lot of chiefs for six Indians" - when compared with those in place in England, where there are many more sites.
I think the issue for Scotland is when you've got one site … you've got a supervisor and you've got a local leader, and you've got a lead in the Government. [ ] …but it feels slightly people falling over each other, and actually the person who gets squeezed out will be the supervisor, and that's the person who needs to grow into the lead role.
The distinctive roles of the Supervisor and the local FNP Lead in NHS Lothian (whose role is to implement the programme at a local level, and to ensure that it fits with and integrates well with other services) were well demarcated. However, in the early days, at least, it was suggested that there was some blurring of roles within Scottish Government and between SG and NHS Lothian, with a lack of clarity about who was responsible for different elements of the implementation process. The range of interests across sectors represented within the programme's strategic management may also reflect rather different perspectives which, in turn, may influence day-to-day management and delivery.
We've come to the view that the most stable person in a system in turmoil is the supervisor, so we're investing more and more in … and helping supervisors; recognising that they're going to have to take on selling it to commissioners and GPs, and the strategic bit as well as the clinical and the team.
Nevertheless, the importance of the Scottish Government's commitment to the programme cannot be over-estimated: it ensured that funding was guaranteed until all clients' children are two years old and, further, it is well established that "buy-in" from the wider organisation can be a critical factor influencing successful implementation. In times of economic constraint, this financial commitment was welcomed.