Learning from 25 years of preventative interventions in Scotland

7. Family Nurse Partnership (FNP)

Family Nurse Partnership: Improving outcomes for children and families

The Family Nurse Partnership (FNP) is an intensive, preventative, one-to-one home visiting programme for young first time mothers. FNP has been evaluated and shown to have led to measurable improvements in outcomes for children and families. Scotland is the first country in the world to deliver the programme at a national level.

Introduction

FNP is an example of a primary preventative intervention. FNP provides a one-to-one home visiting programme for first time mothers aged 19 and under, as well as some aged 25 and under where local capacity exists. It is delivered by a specially trained Family Nurse from early pregnancy until the child is aged 2.

Context

There is a growing international body of evidence which demonstrates that a child’s first years are critical in influencing later life outcomes.^[156] In summer 2007 a Ministerial Task Force on Health Inequalities chaired by the Minister for Public Health was set up by the Scottish Government to agree priorities for cross government activity to reduce health inequalities.

The Task Force’s report (published in June 2008), set out evidence on the wide ranging and deeply damaging inequalities that existed within Scotland and emphasised the importance of the early years in determining future health outcomes. The report set out how:

‘Future health inequalities are, to a large extent, determined from a child's earliest years. This is down to biological factors as well as life circumstances generally. Early responses to what is happening shape future physical and psychological functioning. To help the brain develop children need secure and consistent relationships with others, or else they will not thrive, learn, adapt and form good future relationships’. ^[157]

Many of the Task Force’s conclusions were related to the importance of providing the best possible environment for children’s earliest years and ending cycles of poverty and poor health passed down from parent to child.

Response

The September 2008 Programme for Government committed to ‘work together with local government and other partners to lead a profound shift in culture and service delivery around implementation of the early years/ early intervention framework’.^[158]

Following this the Scottish Government published the Equally Well Implementation Plan.^[159] The Plan included a recommendation to introduce a Nurse Family Partnership pilot in NHS Lothian to provide holistic support services for families with very young children at risk of poor health and other outcomes.

This recommendation was based on evidence gathered to inform a UK Government 2006 Action Plan on tackling social exclusion. The Action Plan set out evidence that the Nurse Family Partnership was ‘highly cost effective’ and ‘effective with families suffering high levels of deprivation’.^[160] A pilot was set up in England in 2007 with some adaptations including changing the name to the Family Nurse Partnership (FNP) in recognition it should be a family led approach.^[161]

Within Scotland FNP was seen as a key intervention to improve outcomes in the early years and break the repeating cycle of poor outcomes often associated with teenage pregnancy. Commitment to this programme, in Scotland, was also discussed as part of the development of the Early Years Framework,^[162] which was focused on giving every child the best possible start in life and was launched alongside Equally Well.

Intervention

The Nurse Family Partnership was developed in the US by Professor David Olds. It is a highly intensive, complex clinical intervention, with the purpose of achieving three core outcomes through development of a relational, therapeutic relationship between the nurse and the client:

• Improving pregnancy and birth outcomes, through improved prenatal health behaviours;
• Improving child health and development, through positive, responsive caregiving; and
• Improving the economic stability of the family, through developing their vision and realising their plans for the future.

The Nurse Family Partnership (in the US) which evolved from the 1970s has been rigorously evaluated through three randomised control trials (RCTs) examining the effects of the programme on first-time, low income mothers. These RCTs have shown significant improvements in the health and lives of first time mothers.^[163] FNP has received the highest possible evidence rating from the Early Intervention Foundation^[164].

FNP has been introduced in a number of countries including England where it has been evaluated through a RCT^[165] and subsequent follow-up evaluation.^[166] FNP is supported by a detailed logic model which includes a wide range of short, medium and long term outcomes to be achieved during programme delivery, at the point of graduation and post programme completion.^[167] FNP is underpinned by a body of academic literature and draws heavily on human ecology theory, attachment theory and self-efficacy theory.

FNP was brought to Scotland under license and piloted in NHS Lothian from late 2009 with client enrolment beginning in 2010. Following successful early implementation^[168] the programme was gradually rolled out across mainland Scotland. Table 1 below shows the roll out of FNP in Scotland.

Table 1: Implementation of FNP across Scottish Health Boards

NHS Health Board

NHS Lothian

Date Recruitment began

Jan 2010

NHS Health Board

NHS Tayside

Date Recruitment began

July 2011

NHS Health Board

NHS Fife

Date Recruitment began

August 2012

NHS Health Board

NHS Greater Glasgow and Clyde

Date Recruitment began

October 2012

NHS Health Board

NHS Ayrshire and Arran / NHS Highland

Date Recruitment began

February 2013

NHS Health Board

NHS Lanarkshire

Date Recruitment began

July 2013

NHS Health Board

NHS Forth Valley

Date Recruitment began

March 2014

NHS Health Board

NHS Grampian

Date Recruitment began

May 2015

NHS Health Board

NHS Borders

Date Recruitment began

August 2015

NHS Health Board

NHS Dumfries and Galloway

Date Recruitment began

October 2018

FNP in mainland Scotland is offered to all young first-time mothers aged 19 or under and some mothers under 25, where there is local capacity to reach them. The programme is delivered from early pregnancy until the child reaches two years old, recognising the important 'window of opportunity' during pregnancy, particularly first pregnancy, and capacity to influence child development during early key life stages. FNP is a voluntary programme, in that it is the decision of the young mother as to whether they want to enrol onto FNP.

FNP is a focused, preventative approach that seeks to support both the mother and her partner (or other adults involved in the child’s care) to develop their own coping skills and strategies to enable them to nurture, care and protect themselves and their children. Family Nurses are experienced, qualified nurses and midwives who undergo extensive, additional training to take on the role of a Family Nurse.

The FNP client group is complex and because of this, the changes they wish to make in their lives are diverse. Programme delivery, therefore, aims to be robust but also flexible. The FNP programme sets out a schedule of structured home visits, with guidance on content. Family Nurses are encouraged to match their schedule of visits and the content of these to individual clients’ specific needs and goals. Family Nurses are provided with an extensive suite of materials to support client engagement and the development of knowledge, skills and confidence.^[169]

Monitoring and Evaluation

As noted above, the original model for the programme was previously evaluated in the US and England. Since its introduction in Scotland in 2009 several evaluations have been carried out. These have included:

• An evaluation of the original pilot of FNP in NHS Lothian (published in 2014^[170]) examining the implementation and operation of the programme and the plausibility of FNP to impact on short, medium and long-term outcomes.
• A qualitative study of FNP (published in 2019) which aimed to distil learning through understanding the experiences of those providing and receiving FNP.
• A mixed methods study examining the experience of FNP clients and family nurses during the Covid-19 pandemic (published in 2021^[171])
• A 10 year analysis of FNP using routine data, of over 9,000 participants that had completed the FNP programme up to 31st March 2021 (published 2022^[172])
• A natural experiment using data linkage comparing the outcomes of mothers and children completing FNP to a comparable control group (published in 2024^[173])

There is a systematic approach to monitoring delivery of FNP. An annual report is produced as part of the licence commitments, and provided to the International NFP Unit in the University of Colorado, Denver. Routine data is collected, in line with the licensing criteria and minimum standards, by Boards and provided for national review annually. This is a subset of the data provided to the Scotland level Annual Report. Boards also collect data monthly in relation to uptake and attrition, and routine data forms are used alongside delivery of the programme and recorded on the FNP Turas system, hosted in NHS Education for Scotland.^[174]

Key Findings

Over the last 15 years a large body of evidence has been collected in Scotland on the effectiveness of FNP in improving outcomes for children and families. This is summarised below in relation to three questions:

1) What value do people delivering and receiving FNP ascribe to the programme?

Qualitative data collected through interviews, focus groups and facilitated discussions^[175] shows that FNP clients, Family Nurses and other stakeholders see FNP as valuable in terms of:

• Helping clients reflect on aspects of their lives that may be negatively affecting them
• Supporting clients to make decisions and take actions that will improve their situations including client’s mental and physical health; safety; self-efficacy and confidence; social and intimate relationships; and housing, education and employment
• Helping to ensure that potentially vulnerable babies are not exposed to harmful situations, and encouraging positive child development through well-informed, sensitive and positive care giving
• Facilitating and enabling positive relationships between clients and other services
• Improving inter-agency working and reducing the workloads of other services.

2) Have the outcomes of children and families receiving FNP improved over time?

The 10 year analysis of FNP published in 2022 reported some improvements in maternal and child outcomes for those participating on the programme. This analysis looked at improvements in outcomes amongst participants on the programme overtime and / or change in comparison to the broader population. Key findings demonstrated:

• A reduction in smoking in the two weeks after enrolment, at 36 weeks gestation and 12 months post birth
• An improvement in breastfeeding initiation and duration of feeding among younger mothers
• In recent years the majority of FNP clients had not consumed alcohol (68%) or taken drugs (94%) during pregnancy, including before they knew they were pregnant
• The majority of FNP children did not have a child development concern
• Overall 95% of FNP children had received all of their immunisations by 24 months, in line with the national average for all children.

The report also set out how, at the national level, there has been a substantial decline in the pregnancy and birth rate among younger mothers over the last 10 years. The number of first time births to mothers aged 19 and under in Scotland is now a third of what it was when FNP was first delivered in 2010.

3) Is there evidence that people completing the FNP programme have better outcomes than those who don’t?

The phased roll out of FNP in Scotland, across a number of years, as set out in Table 1 enabled researchers from the Centre for Trails Research at Cardiff University to conduct a natural experiment using routine data to compare the outcomes of mothers who completed FNP against a control group of mothers who met the eligibility criteria for FNP but were not offered a place on the programme. The study involved linking anonymised routine health, education and social care data comparing outcomes between FNP Clients and Controls across 39 outcomes^[176]. The study found some small statistically significant, differences related to child outcomes. The study found that:

• Rates of breast feeding were statistically significantly higher in the FNP group at 10-14 days and persisted at 6-8 weeks post-partum
• There was a statistically significant reduction in the child’s exposure to second hand smoke over time in the FNP group compared to the Control group, with a greater reduction seen in the FNP group earlier (between 10-14 days and 6-8 weeks) compared to Controls (between 6-8 weeks and 27-30 months).
• A significantly higher proportion of children in the Controls had any newly suspected child development concerns recorded at 27-30 months, with no other differences in any other child development outcomes.
• Statistically significantly more children in the FNP group were registered with a dentist by aged 2 years.

In addition to the differences described above there were also statistically significant differences for sub-groups in relation to child’s school attainment with children that had received FNP significantly more likely to achieve early or first level in writing in NHS Greater Glasgow and Clyde and NHS Fife and Literacy in NHS Fife. This finding is similar to the later Building Blocks 2-6 evaluation in England which found that families visited by a Family Nurse were more likely to achieve a good level of development at school reception age. This effect was strengthened when accounted for child’s month of birth.

The study also found some differences in relation to a range exploratory outcomes. For example, A higher proportion of children born to FNP Clients attended childcare by the 27–30-month review compared to children born to women in the Control group and FNP Clients that were recorded as leaving school after their antenatal booking date remained in school for a longer duration than Controls.

Learning and Next Steps

The successful adaptation and implementation of FNP across Health Boards in Scotland demonstrates the potential to identify effective international preventative interventions and introduce them to a Scottish context.

Evaluating complex primary preventative interventions such as FNP can be methodologically challenging and expensive. It can also be difficult to identify the longer term impacts associated with interventions due to the lengthy timeframes involved and the practical and ethical issues associated with identifying a suitable control group.

However, the incremental way in which FNP was introduced in Scotland, in different Health Boards over a number of years created the conditions that enabled a natural experiment using data linkage. This supported longitudinal analysis of a large number of variables over time. This approach to evaluation generated significant cost savings. The cost of the data linkage in Scotland was £183,000 in comparison with a cost of £5.2m to evaluation the FNP RCT in England. This approach to data linkage could prove to be a model for future evaluations of similarly phased national interventions.

As the longer term benefits associated with FNP become more apparent it may be useful to undertake economic evaluation to better understand the value for money provided by FNP. In doing so it will be important to learn from other early years preventative evaluations, such as Sure Start^[177] where early evaluations were limited in their findings and showed increased service usage in some elements in the early years, however longer term evaluations have demonstrated significant service demand reduction across health care usage and additional education needs alongside increased educational attainment.

In the US where the NFP has been delivered and evaluated over a much longer timeframe there is evidence of longer term positive impacts amongst children and mothers. This includes improvements in mental health, less interactions with the justice system and reductions in use of welfare and other Government assistance^[178].

The majority of mothers that enroll on FNP have had significant complex challenges. FNP clients are young first time mothers, many of whom have experienced anxiety and depression, social deprivation, parental separation. A high proportion have been care experienced or on the child protection register.

Abuse and neglect, mental health issues, homelessness and poverty are much more prevalent in the FNP client group than in the general population. Within this context improving outcomes and addressing deeply entrenched, intergenerational inequalities is challenging. However, the body of evidence collected over the last 15 years provides qualitative and quantitative evidence to show that FNP is making an important difference in improving child and maternal outcomes in the short and long term.