Evaluation of the Family Nurse Partnership Programme in NHS Lothian, Scotland: 3rd Report - Infancy

9 Implementing FNP in Lothian

Key findings

• Local stakeholders from other services were very positive about what they had seen of the impact of FNP on individual clients. However, some reservations were apparent around eligibility criteria, sharing learning and the resources associated with FNP.
• Working relations between the NHS Lothian, Edinburgh FNP team and other services were viewed as good by stakeholders from Midwifery, General Practice and Social Work. Factors supporting this included: initial and ongoing regular and open communication by the FNP team, including attending meetings of other services; shared electronic records (between Midwifery and FNP); new Family Nurses shadowing Midwives; the quality of Family Nurses' work around shared clients (for example, the quality of their written reports in Child Protection cases); and building on pre-existing working relationships.
• Stakeholder suggestions for improving communication between FNP and other services included: more and/or earlier sharing of the theoretical and research base for the programme and how it would work with particular services, and more regular meetings between Family Nurses and GP practices.
• FNP in Scotland was contributing to discussions around supporting Public Health nurses through, for example, links with the Chief Nursing Officer. NHS Tayside (the second FNP site in Scotland) had also begun work around a programme of development for Health Visitors, building on some of the principles of FNP - around motivational interviewing and the nature of leadership and supervision, for example.
• Additional strategic learning from the experience of implementing FNP in Lothian related to:
  • Appropriate handling of media activities involving FNP clients
  • The importance of considering sustainability and thinking widely about the potential benefits of FNP across organisations and divisions from the outset of planning a new site, and
  • The potential of FNP to contribute to learning around co-production with services users.

Introduction

9.1 Previous chapters in this report have focused on the detail and experience of delivering FNP in the first Scotland test site in NHS Lothian, Edinburgh. This final chapter explores broader, strategic-level learning from the experience of implementing FNP in NHS Lothian, Edinburgh. It starts by summarising views of FNP among local stakeholders (from Midwifery, General Practice and Social Work). It then summarises views on potential additional learning from the experience of implementing FNP in NHS Lothian, Edinburgh for both other FNP sites and wider services.

Stakeholder perceptions of FNP

General perceptions

9.2 In Scotland and the UK, FNP is delivered within a wider context of universal and targeted services. Family Nurses need to work with colleagues in health and other services like social work, education, justice and the voluntary sector in order both to meet clients' needs and to comply with regulation around the monitoring and protection of child health and wellbeing. Here, we briefly summarise Midwifery, General Practice, and Social Work statekholders' overall views of FNP and how they would like to see it develop in the future. While it should be born in mind that the number of interviews on which this is based was small and limited to three specific services in one Health Board, it nonetheless gives an indication of the kinds of issues that may need to be considered in trying to develop stakeholder support for FNP in other sites.

9.3 Stakeholders were asked to reflect on what they had thought about FNP when they first heard about it (which in all cases was as a result of plans to introduce it in Lothian - no one reported having heard about it prior to this) and whether their views had changed over time. Those interviewed reported a good understanding of what FNP involved (intensive support for teenage mothers from pregnancy through the first two years of their child's life) and its approaches (early engagement and preventative support delivered via a therapeutic relationship between nurse and client). However, they reported some initial scepticism about specific aspects of the programme among either themselves or their colleagues, focusing on:

• Whether or not the programme would have the same impact when transferred from a US to a UK context
• The strictness of the enrolment criteria (only first-time mothers aged under 20 and identified before 28 weeks gestation are eligible)
• Perceived 'secrecy' around FNP materials and concerns about whether it would be possible to share learning with Health Visitors and incorporate into core practice, and
• The intensity of resources required to sustain the programme within the NHS.

9.4 Some of the reported concern around the likely impact of the programme appeared to have been addressed for these stakeholders, at least in part, as a result of observing benefits for individual clients. They reported, for example, observing healthy outcomes for babies, children staying with mothers in cases where they thought they might otherwise have been removed, feeling the family was better supported in a case where the child was removed, and perceived impacts on the parenting skills and confidence of FNP clients.

In the case of this patient, she had a very, very good outcome, and I'm sure a lot of that was due to the family nurse. Certainly the family nurse was able to intervene on her behalf when there were a couple of controversies at Social Work meetings.

(GP)

I am kind of much more confident that … that the mum had the best chance that she could, and the Family Nurse Partnership played part of that.

(Social Worker)

It wasn't anything that was very measurable, but (…) the contact seemed to have given those parents a level of confidence that … that seemed different to what I would have expected.

(GP)

9.5 However, while these local stakeholders were generally very positive about FNP in terms of both working relationships and the client outcomes they were observing, they reported some ongoing reservations around eligibility criteria, sharing learning and resources.

9.6 Stakeholders indicated that they would like to see eligibility criteria extended, for example to clients aged over 19, fathers, clients who book their pregnancy late or clients who turned down the programme at the first pregnancy. This suggests an ongoing need for clarity and discussion with local stakeholders around eligibility.

9.7 Concern around sharing learning was associated with a belief that it was not possible to pick out key approaches from FNP that could be applied more universally. One view was that it might be preferable in terms of mainstreaming and sharing learning if Family Nurses could be embedded within local Health Visiting or practice Community Nursing teams, rather than being separate teams. It was also suggested that Health Visitors ought to be taught more about what Family Nurses do, even if they cannot spend as much time with clients as a Family Nurse would.

9.8 As discussed in the last evaluation report, Family Nurses and FNP stakeholders felt that in practice sharing learning from FNP had been less focused on what could not be shared from the manual and more focused around what can be learned in terms of, for example, approaches to engaging those less likely to access universal services. But that fact that concerns around sharing learning continue to be expressed by stakeholders may indicate an ongoing need for FNP sites to be clear about how learning can and is being shared with universal services.

9.9 Finally, stakeholders from Midwifery and General Practice reported some ongoing reservations about the financial sustainability and cost of FNP. One view was that if it was shown to make a major different to outcomes, the cost of the programme was worthwhile. Indeed, there were already suggestions from stakeholders that it should be expanded to cover more clients or a wider geographical area. However, at the same time they reported some ongoing tensions relating to the perceived resources spent on FNP in comparison with pressures on resources for mainstream services like Midwifery and Health Visiting.

9.10 This view was reflected in a related comment from those involved in implementing FNP Scotland, who suggested that the more other Public Health Nurses understood about FNP, the more they questioned the support available to them. The further development of support for Public Health nurses was described as a key area to which FNP nationally could contribute in the future. NHS Tayside (the second area in Scotland to deliver FNP) had already begun work on a programme of development for Health Visitors, building on some of the principles of FNP around motivational interviewing and the nature of leadership and supervision. The FNP National Unit (Scotland) had also issued guidance for FNP sites in Scotland around engaging local organisational and development leads in considering the change management implications of introducing FNP, particularly in relation to the Health Visiting and Midwifery workforces.

Stakeholder views on how FNP compares with other services

9.11 The views of stakeholders from Midwifery, General Practice and Social Work on how FNP compared to other services largely echoed those of both Family Nurses and clients (see Ormston et al, 2012; Martin et al, 2011).

9.12 In comparison with universal Midwifery services, FNP was seen as having a different approach to antenatal education, much more geared to teenagers. FNP's role in providing antenatal education was described as helping ease some of the challenges Midwifery experienced in trying to find space in parenting classes for everyone in their caseload. FNP was also seen as more 'intensive' than Midwifery and able to provide more holistic support as a result. Similar comments were also made in relation to health visiting and social work.

9.13 Social Work and FNP were seen as sharing similar values around supporting families; trying to keep them together and helping them access resources. However, differences in their perspectives were also noted. In particular, it was suggested that FNP focused on strengths and on 'early intervention', whereas social workers have to focus primarily on 'preventing risk'.

9.14 In general, the role of different services in relation to clients appeared to be clearly understood by the local stakeholders interviewed for the evaluation. However, a stakeholder form General Practice commented that it could be confusing from their perspective having two services (Health Visiting and FNP) running alongside each other and that it would be helpful to have a list of all the clients FNP are working with in their practice to ensure they know who is looking after which family. A Social Work stakeholder also noted that there had been some lack of clarity around what role the Family Nurse and Health Visitor should play in a case where a child was being accommodated. This had been resolved at the time and had not been a major 'challenge', but it was reported that there had needed to be some debate about roles in relation to the child. In a related comment, the NHS Lothian, Family Nurse Supervisor noted that there had been some confusion around who was the 'named person' for the child for Getting it Right for Every Child purposes, with all the related standards currently stating that it is the Health Visitor. Again, this was not seen as creating major difficulties but was something that needed clarifying and was being looked into by the FNP National Unit (Scotland).

Communication between FNP and other stakeholders

9.15 The stakeholders interviewed for the evaluation had contact with the NHS Lothian, Edinburgh FNP team through a variety of routes: through discussions or meetings about individual clients; via direct contact from the FNP team to inform their service about the programme; through occasional sharing of workspaces; and through involvement in strategic discussions within NHS Lothian about FNP. The level of direct contact they had with the NHS Lothian, Edinburgh team varied across the stakeholders interviewed for the evaluation. However, all were able to comment on aspects of communication and working relations they felt had worked well and less well. Overall, communication and working relations between FNP and individual practitioners around clients was reported to have been good - suggestions for improvement tended to be more at the service to service level.

9.16 Social Work stakeholders reported that it was interesting and challenging to work with someone with an 'undiluted' focus and approach. Even where social workers and Family Nurses disagreed over the best course of action for a client or their child, they reported that FNP's input was valued in ensuring that all views are considered and that they have done everything they can for the family. Stakeholders from General Practice and Midwifery similarly reported that their links with FNP over individual clients were good and that they were able to work together where needed.

9.17 Factors stakeholders identified that appeared to support good working relations and communication between FNP and their services included:

• Regular and open communication from the FNP team when FNP was first being set up
• Ongoing regular meetings and e-mail contact, including members of the FNP team attending meetings of other services to help them better understand what FNP is about and their approach
• The electronic record system within NHS Lothian, which meant that both Midwives and Family Nurses could see what was happening with shared clients
• New Family Nurses shadowing Midwives to get a feel for what is happening in Midwifery
• Family Nurses providing timely and detailed reports to other services (mentioned in relation to social work in particular)
• Individual staff already knowing individual members of the FNP team.

9.18 Midwifery stakeholders felt their service had become a bit more distant from FNP in the recent past. This underlines the need to re-establish links and re-introduce FNP to other services after a break in enrolment 'because these things get lost over time, or put at the bottom of a drawer' (Midwife). In fact, this was already happening in NHS Lothian, with Midwifery reporting that the FNP team were re-visiting Midwifery team meetings and giving out information and contact details again.

9.19 Stakeholder suggestions for improving communication between FNP and other services included:

• More and/or earlier sharing around the theoretical and research base of the programme, as well as how it will work with their service. Both Social Work and General Practice stakeholders commented on this, suggesting that it would be helpful to find out more at the outset about the theoretical background to FNP, what the evidence is for its successes, and how it works with other agencies. A Social Worker commented on how useful a DVD that the NHS Lothian, Edinburgh team had shared with them had been in this respect, while a suggestion from General Practice was that all GPs should be sent summaries of the aims of FNP, what Family Nurses do, how they will communicate with GPs and what the evaluation evidence for FNP shows.
• More regular meetings between Family Nurses and GP practices. It was commented that in comparison with Health Visitors based within GP surgeries, there was less informal regular contact between GPs and Family Nurses. Given this, it was suggested that it would be helpful if Family Nurses could meet with GPs in practices where their clients were clustered to update them on how their clients are doing and how much contact they had with them. It is worth noting here that the FNP National Unit (Scotland) are currently considering issues around organisational preparation for delivering FNP, including how sites can best engage with GPs.

Learning from FNP in Lothian

9.20 The second evaluation report (Ormston et al, 2012) identified a variety of areas of potential strategic learning for other FNP sites and wider services from the experience of implementing FNP in NHS Lothian, Edinburgh. Additional learning points discussed in the third round of evaluation interviews focused on:

• Learning around involving FNP clients in media and publicity around the programme. It was suggested that while the media are very interested in FNP, this needs to be handled very carefully given the vulnerabilities of some clients. The FNP National Unit (Scotland) had worked with Communications colleagues on best practice in this area, drawing on the experience of working with the media around the NHS Lothian, Edinburgh site.
• The importance of considering sustainability from the outset. In terms of the long-term sustainability of FNP in Scotland, it was considered essential for Health Boards to think widely about the potential gains from FNP across organisations and divisions and to encourage connections with local authorities and others from the outset. It was noted that this had been built in to the Expression of Interest process for new FNP sites in Scotland.
• Contributing to learning around co-production with service users. FNP was believed to be contributing to the debate around co-production as an exemplar of an approach that supported people to make sense of their own situation and use their own strengths. It was suggested that there was considerable scope for FNP to work more with other areas - such as Community Nurses working with older people - in sharing learning around this theme.