Evaluation of the Family Nurse Partnership Programme in NHS Lothian, Scotland: 4th Report - Toddlerhood

1 Background and Introduction

About this report

1.1 The Family Nurse Partnership (FNP) programme is a licensed preventative programme which aims to improve outcomes for young first time mothers and their children. It does this through a structured programme of home visits delivered by specially trained Family Nurses from pregnancy until the child is two years old.

1.2 The evaluation of FNP in Scotland focuses on learning from the experience of implementing FNP in the first Scottish FNP test site, based in NHS Lothian, Edinburgh. It focuses on process and understanding how the programme works in a Scottish context.

1.3 This fourth evaluation report focuses on the delivery of the programme in the toddlerhood period (the period when clients' children are 12 to 24 months old, at the end of which clients 'graduate' from the programme and stop receiving Family Nurse visits). Three earlier reports (Martin et al, 2011, Ormston et al, 2012, Ormston and McConville, 2012) focused on (a) early implementation and early pregnancy, (b) late pregnancy to around six weeks post-partum, and (c) infancy (six weeks to 12 months). This report focuses explicitly on new findings emerging from the data collected for the toddlerhood period. A final evaluation report, due for publication Autumn 2013, will summarise key learning from across all four of the more detailed reports on individual 'phases' of FNP.

1.4 The remainder of this introductory chapter describes the FNP programme and its implementation in Scotland in more detail. Chapter 2 briefly outlines the evaluation methods and aims, while chapters 3 to 9 discuss the main findings from this phase of the evaluation.

The Family Nurse Partnership (FNP) programme

1.5 The FNP programme was developed in the USA (where it is called the 'Nurse Family Partnership' (NFP) programme) by Professor David Olds (University of Colorado, Denver). Based around a structured programme of home visits to the mother (and, after birth, the mother and child) delivered by trained Family Nurses, it is a preventative programme, aimed at first time mothers and their babies. The programme's goals are to improve pregnancy outcomes, the health, development and well-being of first time parents and their children, and families' economic self-sufficiency. For a summary of the key theoretical approaches underpinning FNP, see Olds (2006).

1.6 FNP is a licensed programme, which ensures that the original research conditions under which improved outcomes for mothers and children have been observed are replicated in new sites. As such, new sites may only run the programme and access the materials and training associated with it if they sign up to an agreement to implement it according to specified fidelity requirements. Developed by the University of Colorado (whom the licensing relationship is with) and referred to in the FNP Management Manual (Department of Health FNP National Unit, adapted for Scottish FNP sites, November 2010) as 'Core Model Elements', these licensing requirements cover:

• the visiting schedule (specifying the frequency of Family Nurse visits to clients throughout pregnancy until the child is two)
• staffing requirements (for example, the professional and personal characteristics of Family Nurses)
• client eligibility (for example, the point in pregnancy by which mothers should be enrolled), and
• the organisational structures and processes needed to support the programme (including training, supervision and administrative support).

1.7 In addition, the FNP Management Manual sets out various fidelity goals - described as 'stretch goals'^[1]. The fidelity 'stretch' goals cover client retention, visit 'dosage' (in terms of the numbers and length of visits to clients at different stages of their participation in the programme), and coverage of different 'domains' or topics during visits. A full list of the FNP Core Model Elements and Fidelity 'stretch' goals can be found in the annexes of the first evaluation report on the pregnancy phase (see Martin et al, 2011).

Testing FNP in Scotland

1.8 The background to and history of FNP's introduction in the UK is described in Martin et al (2011). The first FNP test site in Scotland commenced in NHS Lothian, Edinburgh, with the first clients enrolled from January 2010. Since then, additional Scottish FNP sites have been introduced in NHS Tayside (from July 2011) and in Greater Glasgow and Clyde, Ayrshire and Arran, Fife, Lanarkshire and Highland (in 2012-2013). FNP in Scotland is coordinated by the FNP National Unit (Scotland). Formerly based in the Scottish Government, this Unit has now moved to NHS Education for Scotland (NES), although the licence for the programme remains with the Scottish Government.

FNP in NHS Lothian, Edinburgh

1.9 The first NHS Lothian, Edinburgh FNP test site is based in Edinburgh Community Health Partnership (CHP) and delivered by NHS Lothian. The NHS Lothian FNP Edinburgh delivery team was initially comprised of a Supervisor, six Family Nurses, and an Administrator/Data Manager, supported by a local FNP Lead in Lothian. The team has subsequently undergone a number of changes reflecting staff departures, expansion, and new responsibilities among the existing team.^[2]

1.10 FNP was offered to all eligible women within Edinburgh CHP during the recruitment and enrolment period. Of those, 148 women who met the key criteria for participation (living within Edinburgh CHP, first time mothers, aged 19 or under at Last Menstrual Period, and under 28 weeks gestation) were enrolled with FNP in NHS Lothian, Edinburgh over a nine month period in 2010. The first clients delivered their babies in April 2010, so the first cohort of clients started to 'graduate' from April 2012 (when their children turned two years-old), with the full first cohort completing the programme by the end of April 2013.

1.11 The first NHS Lothian Family Nurse team started recruiting a second cohort of clients from 25^th September 2012, with a full second cohort expected to be on board within 12 months. Matched funding (Scottish Government and NHS Lothian) has also now been secured to enable NHS Lothian to expand their programme, with an aspiration to move to small scale expansion (i.e. being able to offer the programme on an ongoing basis to every eligible client in the area, without a break in enrolment).