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

7 Referrals and Transitions

Key questions and outcomes

7.1 Specific outcomes from the monitoring and evaluation framework of relevance to this chapter include:

• Referrals to other services, and
• Use of community resources and supports.

7.2 Both of these are intended to support the higher level outcome of mothers feeling more supported and less anxious or depressed. As noted in earlier evaluation reports, the relationship between FNP and other services is also of wider interest in terms of understanding how the programme is being implemented in a Scottish context and what issues other FNP sites may encounter in relation to joint working practices.

Key findings

• Family Nurses referred clients to a range of services in toddlerhood. Once again, clients appreciated the support from their Family Nurses in linking them in with housing services and in helping them access financial support.
• As noted in previous evaluation reports, the availability and perceived suitability of services for young mothers can be an issue - for example, a lack of formal services for young parents of two year-olds, alongside a lack of confidence among clients about attending group-based sessions on their own.
• The NHS Lothian, Edinburgh FNP team identified various challenges and enablers to working with Health Visiting around client transition to universal services.
• Challenges included: Public Health Nurse/Health Visitor concerns about client expectations of their service; specific Public Health Nurses/Health Visitor expectations of FNP clients (expecting them either to be very vulnerable or that FNP will have resolved any difficulties they may face); and practical issues around handing over large paper files.
• Enablers included: joint visits with the Family Nurse (including meeting in advance of visiting the client's home); early and ongoing communication with Health Visiting colleagues; work within Lothian to increase understanding of strengths-based approaches; and the reintroduction of the 27 month child health check.
• Family Nurses felt there were still some challenges in working relations between FNP and other services due to differences in their ways of working and a lack of understanding of what FNP does. However, they also felt that over time this was changing. The team reported using some of the communication skills learned as part of FNP to help convey the programme and its philosophy and to address any concerns among colleagues in other services.

Introduction

7.3 'Human ecological theory' (one of the key theories underpinning FNP) highlights the importance of the social and community, as well as family context, in influencing parenting. As such, a key role for FNP is in linking clients with other services and resources that may be able to support them. In a UK and Scottish context, this role clearly becomes particularly important during toddlerhood towards the point of transition from FNP to universal services when the client's child turns two years-old. Although Family Nurses work with a range of existing services, which may continue after graduation, the client will be referred to Public Health Nursing/Health Visiting services for ongoing support following graduation. Links to Health Visiting are therefore of particular interest in this context.

7.4 This chapter summarises the number and types of referrals made by Family Nurses during the toddlerhood phase of the programme, discusses client and Family Nurse perspectives on the impact of those referrals, explores views of the transition to universal services, and summarises views within the NHS Lothian, Edinburgh Family Nurse team on working relations between FNP and other services and what they have learned about supporting these.

Referrals to other services during toddlerhood

7.5 During toddlerhood Family Nurses made 240 referrals. This is fewer than the number of referrals in infancy (where there were more than 400) and greater than the number in pregnancy (166 referrals). In comparison to the infancy phase, while there were fewer referrals to health care services for clients and for their children in toddlerhood, there were more referrals to community support and social care. There were also a greater number of referrals to 'other' organisations. These included children and family centres (Family Nurses were probably making sure support was in place for clients once they had graduated from the programme). Compared to infancy, more referrals were also made to a number of organisations which provide assistance in accessing furniture (this was due to a new initiative through Save the Children).

Table 7.1: Numbers of clients referred to services

	Pregnancy phase	Infancy phase	Toddlerhood phase
Health-related services
Smoking cessation	17	<5	5
Mental health services	7	9	<5
Sexual health services	-	8	<5
Antenatal classes	24	NA	NA
Health care services (client)	84	70	42
Injury prevention	NA	6	<5
Health care services (child)	NA	53	33
Other services
Financial assistance	15	34	13
Social care (including child protection/child in need and adult disability services)	10	20	23
Community Support	<5	11	20
Job training	-	14	<5
Housing services	9	12	6
Legal Services	<5	<5	<5
Childcare	-	<5	<5
Breastfeeding support	NA	<5	0
Educational programmes	-	<5	0
Development referral	-	<5	<5
Other *	13	48	70

* In toddlerhood, 'other' services included: Avenil Trust, Best Buddies Volunteer, Buttle Trust, Child and Family Centre, Children's Centre, Community Group, DALO Support, Early Years Centre, Eat Learn Sleep, ESD, EVOT, FAB Pad, Fire Brigade, General Benefits Advice, 'Get On', Greengables Family Centre, Healthcare Academy, Lifeline Charity, Link Living, Mum & Toddler Group, Parenting Support, Police, Police Check, Prince's Trust, Rathbone, Save the Children, Tax Credits, Working for Families.

7.6 The NHS Lothian, Edinburgh Family Nurse team commented on the need to plan ahead during toddlerhood to identify the kinds of services clients might require on transition from FNP. However, they also suggested that there were not many general projects for young mums in the local area to support clients after graduation. One view was that in England, more additional programmes had been developed partly in response to FNP and that there was more of a 'supported landscape' for clients to graduate into. In Edinburgh, there was perceived to be something of a gap in the landscape around formal services for young parents of two year-olds. However, the team reported that they had successfully worked with children's services, who had worked hard to ensure that services were in place to meet identified needs at the time of transition. They reported that, before graduation, Family Nurses were thinking about (and making contact with, where needed) the sorts of projects that were available and suitable for their clients' needs - for example, considering whether individual clients felt isolated, needed to get into normal play groups, etc.

[Family Nurse] was very helpful in making sure that I wasnae just left and forgotten about, she made sure that I had everything that I needed before and I had that support

(Client 63)

Perceived impact of FNP referrals on clients

7.7 Clients' narratives about the impacts of referrals made for them by FNP during toddlerhood echoed those discussed in earlier evaluation reports. They reported FNP linking them to community groups or services they were unaware of and to services they were not sure how to access or may not have accessed on their own. Examples of the kinds of referrals clients mentioned during toddlerhood included:

• 'Rhymetime' (library sessions for parents/carers and children aged 0-4)
• Mother and Toddler Groups.
• Financial grants
• Referrals to agencies that would help them get furniture
• Services offering advice on housing. Again, the support that Family Nurses provided in accessing and communicating with Housing services - including help with writing and/or responding to letters from the council, making phonecalls on their behalf, and putting them in touch with Housing Officers, was praised by clients.

7.8 As in earlier reports, clients gave examples where they felt that they would not have been able to access resources without these referrals from FNP.

She set me up with, it was Save the Children charity, which got me help with vouchers to get help with kitchen things, because I went in to a new house, and I got toys for (child) and vouchers and things. (…) So she was really helpful. I wouldn't have got any of that if it wasn't for (Family Nurse).

(Client 9)

7.9 However, as reported in Ormston and McConville (2012), accounts of clients and Family Nurses suggested that the impact of some referrals could be limited by both service and client-related barriers to taking up these referrals. For example, while some clients said that Mother and Toddler groups provided valuable social and emotional support for them as well as their child, other clients did not take up referrals to these groups. While one client view was that they simply did not have time to attend such groups because they already had busy social lives, others cited more problematic barriers: feeling uncomfortable around people they did not know; feeling excluded by the other mums; a dislike of crowds/groups; and a lack of confidence to attend groups alone. Family Nurses reported accompanying clients to attend community groups where they felt they lacked the confidence to attend alone. However, they also reflected that accompanying a client to a group once might not always be enough, and suggested this was something they might try and do more of in the future - though clearly doing so would have time implications for FNP teams.

Transitions to universal services

7.10 As discussed in chapter 3, FNP is a time-limited programme. Both clients and Family Nurses are made aware from the outset that their involvement will stop once the child turns two years-old. At this point, clients are 'transitioned' to universal services. In particular, Public Health Nurses/Health Visitors become the 'named person' (first point of contact for children and families) and takes over delivery of Hall 4 ('Health for All Children' - the Royal College of Paediatrics and Child Health recommended programme of routine health checks and health promotion activities) for the child until they start primary school.

7.11 Chapter 3 of this report has already discussed client and Family Nurse perspectives on graduation and transition from FNP. Here, we focus on Family Nurse views of working relations with Public Health Nurses/Health Visitors and other key services around the graduation period. As the evaluation did not involve interviews with other services around the graduation phase, this report can only comment on perceptions of working relations between FNP and other services around this period from the point of view of the NHS Lothian, Edinburgh FNP team.

Perceptions of working with Health Visiting around transition

7.12 The NHS Lothian, Edinburgh FNP team identified various challenges and enablers in working with Public Health Nursing/Health Visiting colleagues around client transition. In terms of challenges, the team had carried out an audit of 10% of transferred clients which involved seeking feedback directly from Public Health Nurses/Health Visitors about the transition process. The team noted that while most of this feedback was very positive, Health Visiting colleagues were also asked about any problems or anxieties they had about receiving FNP clients. These had included:

• Their capacity to deal with FNP paper files (as these are often large and Public Health Nurses/Health Visitors have limited storage for their own notes)
• Concerns about clients having expectations of very regular contact. The team felt that this generally would not be the case, however, as FNP does reduce contact over the toddlerhood period (to monthly in the last three months).
• Worries about not being able to get hold of FNP clients easily.

7.13 There was a perception among the NHS Lothian, Edinburgh FNP team that sometimes Public Health Nurses/Health Visitors tended towards a view of FNP clients being at one end or other of a spectrum - either expecting all clients to be very vulnerable at transition or expecting clients to graduate with all of their problems fully resolved. According to the FNP team, this view was not seen to capture the full complexity of the programme.

7.14 These kinds of expectations were viewed as requiring active management by the FNP team. The joint visit with the client's new Public Health Nurse/Health Visitor (discussed in Chapter 3) was viewed by the FNP team as a key factor that helped facilitate good joint working around client transition. Prior to client graduation, the NHS Lothian, Edinburgh FNP Supervisor had elicited the views of the Health Visiting Service by questionnaire to inform the transition process. Eighty-six per cent of Public Health Nurses/Health Visitors agreed that a joint visit with the client would be helpful. From the perspective of the FNP team these visits were key to ensuring clients' engagement with universal services. The FNP team did, however, report some early challenges around joint visits, relating to Public Health Nurses/Health Visitors making comments that clients perceived as critical, for example about clients' living environments. They gave examples where such comments lead to clients indicating they would find it hard to engage with the Public Health Nurses/Health Visitor subsequently. This prompted to a decision that Edinburgh Family Nurses would meet with Public Health Nurses/Health Visitors in advance of going to visit the client, in order to talk through the client's background, to try and avoid such situations in the future.

7.15 The team also cited other work initiated by NHS Lothian to support understanding of FNP and of strengths-based approaches^[20] to working with clients among Public Health Nurses/Health Visitors and others. This included a new package of training for Health Visiting teams focusing on strengths-based approaches, and ongoing communications from the FNP team around the broader principles of FNP, both through their every day contact with Public Health Nurses/Health Visitors and via the team's involvement in delivering training to other NHS staff. The team commented on the importance of building good links with Health Visiting from as early on in the programme as possible to underpin successful joint working around transition. They also noted the importance of reinforcing to fellow professionals that although the relationship with the client ends at the point of transition, the Family Nurse was still contactable for professionals.

7.16 Other enablers to successful joint working with Health Visiting around transition included:

• Public Health Nurses/Health Visitors being flexible about communication options with clients - one Family Nurse gave an example of a Public Health Nurses/Health Visitor offering the client her mobile number in order to keep in touch.
• The reintroduction (from 2012) of the 27-30 month child health review for children in Scotland. The team felt that this came in at the right time for FNP in terms of ensuring that there is a scheduled meeting with Public Health Nurses/Health Visitors three months after client involvement with FNP ends. Moreover, in Lothian this check uses ASQ (Ages and Stages Questionnaire), which clients are familiar with from FNP, ensuring a more 'joined-up' experience for clients.

Joint working with other services

7.17 The NHS Lothian, Edinburgh FNP team were keen to emphasise that transition is not just about working with Health Visiting colleagues. Depending on the client's needs, transition could also involve considerable joint working with other services, like social work, children's centres, third sector key workers, and General Practice. Where clients' cases were more complex, the team highlighted the need to ensure that everyone involved is aware when FNP finishes.

7.18 From the NHS Lothian, Edinburgh FNP team's perspective, a common challenge around joint working with other services is communicating the strengths-based approach of FNP. This has been discussed in more detail - particularly in relation to Social Work - in previous evaluation reports (Ormston et al, 2012, Ormston and McConville, 2012). By the end of toddlerhood, the FNP team believed that their training in motivational interviewing and experience of delivering the programme was enabling them to use FNP approaches in communications with professionals as well as clients - listening, thinking through the issue, and working with them to address any concerns. The team reported seeing strengths-based approaches reflected (at least to an extent) in the language of other colleagues in meetings:

I've seen that change over the time and, you know, in that our strength based approach has been, if not adopted by some of our social work colleagues, certainly a bit more mirroring anyway.

(Family Nurse 6)

7.19 However, there remained a view among the NHS Lothian, Edinburgh FNP team that while the language of 'strengths-based' approaches had become more common over the last three years, there were still some gaps between how other services approached working with young parents and FNP's philosophy. For example, while the team felt that understanding of FNP was now much stronger among Edinburgh social work teams, they nonetheless felt that social work remained generally more reactive, and less likely to work with clients' existing strengths.

7.20 The team also reported that, by the later toddlerhood period, their working relationships with other services were improving in general because people had more knowledge about how FNP works, "most people have actually embraced FNP". At the same time it was noted that working relations varied across the services they worked with - for example, in relation to children's centres while one Family Nurse view was that these centres had 'really embraced' FNP, another was that 'there's still work to do, particularly with some centres'. Expanding the programme to new areas of Lothian also meant that the team were starting again in addressing concerns and communicating the nature and purpose of FNP to services in those areas. Nonetheless, their experience of delivering FNP to the first cohort meant that the team found such networking more straightforward than last time (since they could anticipate questions and concerns), if not any less time consuming.

Key learning around joint working

7.21 Family Nurses discussed what they would share with new FNP teams about how FNP engages with other services (particularly around child protection). They suggested that considerable preparatory work was needed with other agencies to talk about what FNP is and does. An ongoing need for engagement and communication with other services, particularly as sites expand, is also apparent from the experiences of the NHS Lothian, Edinburgh FNP team. The discussion above suggests that using some of the communication skills teams learn for their work with clients with other professionals can help support understanding of the programme. Meanwhile, joint visits with Public Health Nurses/Health Visitors appear useful in supporting successful transition from the perspective of FNP teams. However, further work may be needed to explore in more detail how Public Health Nurses/Health Visitors and clients view these joint visits (as noted in Chapter 3, by their fourth evaluation interviews, most clients had yet to receive a joint visit).