Family Nurse Partnership Programme (FNP)
Background
It is estimated that between 2 and 5% of children in UK experience multiple deprivation and poor outcomes, incurring high cost to the public purse and society.
Recent neuro-scientific evidence shows how for these children negative experiences and poor parenting in pregnancy and very early childhood can do lasting harm to a child's brain development, behaviour, learning and long term health. There is, therefore, a strong case for intervening early with powerful programmes known to make a difference for these vulnerable children.
FNP is a preventative programme for vulnerable young first time mothers. It offers intensive and structured home visiting, delivered by specially trained nurses, from early pregnancy until the child is 2. FNP has 3 aims:- to improve pregancy outcomes; child health and development; and parents' economic self-sufficiency. The methods are based on theories of human ecology, self-efficacy and attachment, with much of the work focused on building strong relationships between the client and Family Nurse to facilitate behaviour change and tackle the emotional problems that prevent some mothers and fathers caring well for their child.
FNP has brought a different way of working with the neediest families. It is strength based and focuses on an expectant mother's intrinsic motivation to do the best for their child. It consists of structured home visits using materials and activities that build self-efficacy, change health behaviour, improve care giving and increase economic self-sufficiency. At the heart of the model is the relationship between the client and the nurse. A therapeutic alliance is built by specially trained nurses, which enables the most at risk families to make changes to their health behaviour and emotional development and form a positive relationship with their baby.
FNP is a licensed programme, developed in the US at the University of Colorado, where it is known as the Nurse-Family Partnership (NFP). Over 30 years of rigorous research has shown significant benefits for vulnerable young families in the short, medium and long term across a wide range of outcomes including:-
- improved early language development, school readiness and academic achievement
- improvements in antenatal health
- reductions in children's injuries, neglect and abuse
- improved parenting practices and behaviour
- fewer subsequent pregnancies and greater intervals between births
- increased maternal employment and reduced welfare use
- increases in fathers' involvement
- reduced arrests and criminal behaviour for both children and mothers
In an international review by The Lancet in 2009 the FNP was named as one of only 2 programmes shown to prevent child maltreatment.
Cost savings in the US are substantial, ranging from $17,000 to $34,000 per child by the time they reach 15, with a $3-5 return for every $1 invested. Significant expansion is planned in the US on the back of the Obama Health Bill.
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FNP in the UK
FNP has been tested in England since April 2007 with over 6000 families having received FNP so far. There are now teams in 55 LA/PCT areas, and a planned expansion to double the capacity of FNP to support 15,000 families in England by 2015 (DH Operating Framework 2011-12). It is estimated that the average local cost of FNP per client is £3,000 year.
FNP is now being tested in Scotland for the first time in NHS Lothian City of Edinburgh Community Health Partnership (Edinburgh CHP). The testing of FNP for the 3 years that the programme takes to deliver, is fully funded by the Scottish Government: £1.6m. NHS Lothian has a team of one Family Nurse Supervisor, 6 Family Nurses and one Administrator/Data Manager and supports 145 families.
A second FNP site has now commenced in July 2011 in NHS Tayside, the area with the highest teenage pregnancy rate in Europe. This FNP site will support approximately 295 families in Dundee City and the Tayside area of Angus and Perth and Kinross. The programme is being funded by the Scottish Government: £3.2m with a contribution by NHS Tayside. The NHS Tayside Team consists of 2 Family Nurse Supervisors, 12 Family Nurses and 2 Administrator/Data Managers.
Work is ongoing within Scottish Government to support the recent manifesto commitment to "rollout FNP across Scotland".
FNP is targeted on teenage first time mothers as a large body of research shows this group have a high level of need and that their children are at high risk of poor outcomes in the future. US evidence also shows that it is young disadvantaged first time mothers who benefit most form the programme. 85% of FNP mothers have incomes below the poverty line, 43% very low incomes and 75% no/minimal qualifications.
FNP is being evaluated in England through a formative evaluation of the first 10 sites, which will report early in 2011; and an RCT in 18 sites which will report in 2013.
The testing of FNP in NHS Lothian will be evaluated by an externally commissioned research team and report in 2013, the focus being on the transferability of this model recognising that the findings from RCT in England will also have a significant impact for FNP development n Scotland. The first evaluation report is available at http://www.scotland.gov.uk/Publications/2011/07/28142203/0
Early signs from this evaluation show that the programme is well received by clients, attrition is low at this stage and enrolment is high. Education and training for the role is highly regarded by the Family Nurses and links with wider services such as housing and social work are effective.
Early learning from England and early impacts look promising;-
- high levels of engagement with hard to reach young parents, including fathers - 82% of those offered the programme enrolled
- strong engagement with fathers. More than half the fathers and partners had been present for at least one FNP visit
- enthusiastic support from nurses, who are seeing changes take place in health behaviour, relationships, parental role and maternal wellbeing. They have also reported that their clients are more confident as parents, were playing with their children more, wanted to learn, and had aspirations for the future
- reduced smoking during pregnancy and increased rates of breastfeeding
- the education and training is highly valued by Scottish Family Nurses and the model of supervision involving a psychologist is considered imperative to the role.
FNP in England is either connected to or delivered from Sure Start Children's Centres (CC) in many areas and Family Nurses encourage clients to use CC services, particularly in preparation fo the end of the programme when children reach 2. Family Nurses also work closely with public health nurses/health visitors and midwives and professionals from other services for children, young people and families where additional needs are identified, particularly in relation to social care and safeguarding.
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FNP Evidence
A strong rigorous US evidence base developed over 30 years has shown FNP benefits the most needy young families in the short, medium and long term across a wide range of outcomes helping improve social mobility and break the cycle of inter-generational disadvantage and poverty.
Evidence from 3 large scale trials which have followed children and families up to age 19 points to significantly improved health and wellbeing for disadvantaged children and their families including:-
- improved early language development, school readiness and academic achievement
- improvements in antenatal health
- reductions in children's injuries, neglect and abuse
- improved parenting practices and behaviour
- fewer subsequent pregnancies and greater intervals between births
- increased maternal employment and reduced welfare use
- increases in fathers' involvement
- reduced arrests and criminal behaviour for children (at 15) and mothers
The benefits are greatest where the mother is young (teenage), has low psychological resources (low IQ, poor mental health, low SES/living in poverty) which is consistent with the eligibility criteria used to target the programme on first time teenage mothers in England.
Cost savings from FNP are substantial with savings of between $17,000 and $34,000 per child by the time they reach 15, £3-$5 for every $1 invested, for high risk groups.
In an international review by The Lancet in 2009 FNP was named as one of only 2 programmes shown to prevent child maltreatment.
FNP is consistently rated by high quality evidence reviews as one of the most effective preventative programmes for vulnerable young families.
Recently published US evidence provides further evidence of FNP effects enduring through childhood and into adulthood. This showed that FNP improves school achievement, reduces the use of cigarettes, alcohol or marijuana and anxiety and depression amongst 12 year olds and, also reduced arrests and convictions for girls up to age 19. The life course of FNP mothers was improved through strengthened mother-partner relationships, a greater sense of mastery, less parenting role impairment due to drugs and alcohol use and reduced family poverty. The Government saved more than the cost of the programme in welfare payments alone by the time the children were age 12.
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More Specific Detail on Benefits
FNP improves pregnancy outcomes, child health and development and mother's life course in the short, medium and longer term. In the US research FNP children and mothers, mainly those who were high risk with low psychological resources, compared to children and mothers in the comparison group had:-
Improved Pregnancy Outcomes
79% reduction in premature birth amongst mothers who smoked
Fewer pregnancy related complications and infections
31% fewer closely spaced subsequent pregnancies
Improved Child Health and Development
Increase in Children's School Readiness
50% reduction in language delays at 21 months
67% reduction in behavioural/intellectual problems at age 6
Increase in Academic Achievement
26% higher scores on school reading and maths achievement in Grades 1-3 **
Better Mental Health and Risk Taking Behaviour
Lower rates of anxiety and depression at age 12
Less use of tobacco, alcohol and marijuana at age 12
Girls had fewer pregnancies by age 19
Reduction in Criminal Activity
59% reduction in child arrests at age 15
90% reduction in PINS (US equivalent of supervision orders)
Reduced Child Abuse and Maltreatment
39% fewer injuries
56% reduction in emergency room visits for accidents and poisonings
48% reduction in child abuse and neglect
Improved Maternal Self Sufficiency and Life Course Development
Fewer Unintended Subsequent Pregnancies
23% fewer subsequent pregnancies by child age 2
32% fewer subsequent pregnancies
Increase in Labour Force Participation by the Mother
83% increase by the child's fourth birthday
Reduction in Welfare Use
20% reduction in months on welfare
Saved the government over $12,000 per family in welfare payments alone by time children aged 12,
greater than the programme cost os $11,511
Increase in Father Involvement
46% increase in father's presence in household
More Sustained Relationships with Partner
18% longer with current partner
Longer time with an employed partner
Reduction in Criminal Activity
60% fewer arrests
72% fewer convictions
Put another way, FNP families compared to comparison group had:-
At Age 19
Child
43% fewer arrests (between 15 and 19, girls)
58% fewer convictions (between 15 and 19, girls)
57% fewer lifetime arrests (girls)
66% fewer lifetime convictions (girls)
had fewer children (girls)
At Age 15
Child
48% less verified incidents of child abuse and neglect
59% reduction in arrests
90% reduction in adjudication as persons in need of supervision (PINS) for incorrigible behaviour
Mother
61% fewer arrests
72% fewer convictions
20% less time on welfare *
32% fewer pregnancies
19% fewer subsequent births
At Age 12
Child
Improved academic achievement **
Less use of cigarettes, alcohol or marijuana
Reduced levels of clinical and borderline anxiety and depression
Mother
Longer partner relationships
Less time on welfare and food stamps
Less money from Government for welfare assistance
Less role impairment due to alcohol and drug use
At Age 9
Child
Lower mortality from preventable causes *
26% higher scores on school reading and maths achievement in Grades 1-3 **
Mother
12% less time on welfare since birth of child
10% less time on food stamps
18% more time with current partner
41% fewer substances used in last 3 years (illegal drugs or moderate to heavy alcohol use) *
21% longer intervals in months between birth of first and second child
Age 6
Child
67% reduction in behaviur and intellectual problems
Age 4
Child
50% reduction in language development delay (standardised effect size 0.31) **
Better behavioural development and executive functioning **
Mother
20% longer interval between 1st and 2nd births
83% increase in labour force participation
46% increased father presence in household
Age 2
Child
50-70% fewer hospitalisations for injuries and ingestion
50% reduction in language development delay at 21 months
Mother
23% fewer subsequent pregnancies
31% fewer pregnancies within 6 months of birth of first child
Fewer beliefs about child rearing associated with child abuse and neglect
Pregnancy and Birth
25% reduction in cigarettes smoked amongst smokers
Improvements to diet
Fewer pregnancy related complications
79% reduction in premature birth amongst mothers who smoked
Increased birth weight amongst very young mothers
The above information is drawn from 3 different NFP Trials, each of which has followed families up at different points in time and measured different things which is why different outcomes are evidenced at different ages. This list sets outs the main benefits observed, it isn't exhaustive. There were also a number of measures that showed no significant differences between the FNP group and the comparison groups, again these varied between the trials and time points.
*only significant at 0.10
**for mothers with low pyschological resources
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Cost Effectiveness
US evidence shows cost savings from FNP are substantial with up to $5 saved for every $1 invested by the time the children were 15, for high risk groups.
Cost savings in the US range from $17,000 to $34,000 per child by the time they reach 15, with a $3-5 return for every $1 invested.
US evidence shows programme costs recovered by the time children reached 4 years oldand that savings grow over time.
Most savings are to the public purse, in form of reduced welfare payments, reduced criminal justice expenditure and increased taxes due to increased earnings.
Recently published US evidence suggests that NFP(FNP) saves the government substantial amounts in welfare payments alone with $12,300 saved per family between the child being born and reaching 12 years old.
Washington State Institute in its rigorous analysis of cost effective evidence based programmes has consistently rated NFP as one of the most cost effective preventative programmes for reducing crime, child abuse and maltreatment and risky behaviour amongst youths.
Too early to say whether FNP is cost effective in England and Scotland but has potential for substantial cost savings by preventing adverse outcomes. For example, if FNP prevents 250 children going into foster care it will save almost £7m in foster care costs in any one year and if it prevents 20 cases of serious conduct disorder it could save society £4.5m over the lifetime of these children.
In UK, the local cost of delivering programme is estimated to be around £3,000 per client per year.
A team of 4 Family nurses, one Family Nurse Supervisor is estimated to cost £300k.
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FNP and Other Early Childhood Programmes
The size of FNP effects are relatively large compared to other home visiting programmes and FNP is consistently rated by high quality reviews of evidence based programmes as one of the most effective preventative home visiting programmes for vulnerable young mothers and their children (e.g. Aos 2004, 2008, 2009, Blueprints Centre for Violence Prevention, Coalition for Evidence based Policy).
FNP has many of the features identified by research as associated with effective early childhood interventions including:-
- focus on specific populations
- uses evidence based implementation practices
- provides intensive services
- involve both parents and child
- has mechanisms for ensuring fidelity to programme model is achieved so benefits are reproduced
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Evidence on FNP in England and Implications for Scotland
As we are at a very early stage of testing FNP in Scotland it is important to note the findings and lessons learned across the sites in England, although early signs are promising in Lothian with a very high uptake rate by those eligible for the programme and low attrition one year into the programme delivery. Family Nurses report that the education and training experience is of an extremely high quality and equips them well to undertake this new role.
FNP is being evaluated in England through a formative evaluation of the first 10 sites, which has reported interim findings and will report finally early in 2011; and an RCT in 18 sites which will report in 2013. The RCT will assess whether FNP benefits families over and above universal services and offers value for money. Outcomes being measured include smoking during pregnancy, breastfeeding, admissions to hospital for injuries and ingestions, further pregnancies, and child development at age 2.
Early evaluation of FNP in England points to:-
- high levels of engagement with hard to reach families. Around 87% of those offered the programme enrol on it and a high proportion continue to engage with the programme until their child reaches 2 years old. 85% of FNP mothers have incomes below the poverty line, 43% very low incomes and 75% no/minimal qualifications
- strong engagement with fathers. More than half the fathers and partners had been present for at least one FNP visit
- enthusiastic support from nurses, who are seeing changes take place in health behaviour, relationships, parental role and maternal wellbeing. They have also reported that their clients are more confident as parents, were playing with their children more, wanted to learn, and had aspirations for the future
- early signs that the programme is having a positive effect on reducing smoking during pregnancy and increasing rates of breastfeeding
- nurses report that FNP is playing a key role in protecting children by ensuring that children/families who need to be protected are identified early, preventing children entering the child protection system and working families so they are able to leave child protection system.
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References
- Olds, D.L., Henderson, C.R. Jr., Phelps, C., Kitzman, H., & Hanks, C. (1993). Effect of prenatal and infancy nurse home visitation on government spending
- Karoly, Lynn A., M. Rebecca Kilburn, Jill S. Cannon, 2005. Early Childhood Interventions: Proven Results, Future Promise. Santa Monica, Calif.: RAND Corporation.
- S.Aos, R. Lieb, J. Mayfield, M. Miller, & A Pennucci. (2004). Benefits and costs of prevention and early intervention programs for youth. Olympia: Washington State Institute for Public Policy, Document No. 04-07-3901
- Stephanie Lee, Steve Aos, and Marna Miller. (2998). Evidence-based programs to prevent children from entering and remaining in the child welfare system: Benefits and costs for Washington. Olympia: Washington State Institute for Public Policy, Document no. 08-07-3901
- Julia Isaacs. (2007). Cost-Effective Investments in Children. (Washington, D.C.: Brookings Institution). http://www.brookings.edu/papers/2007/01childrenfamilies_isaacs.aspx
- Kitzman, H. J., Olds, D.L., Cole, R.E. et al (2010). Enduring Effects of Prenatal and Infancy Home Visiting by Nurses on Maternal Life Course and Government Spending - Follow up of a Randomized Trial Among Children at Age 12. Arch Pediatr Adolesc Med. 2010; 164 (5):419-424
- 1 Olds, D.L., (2006). The Nurse-Family Partnership: an evidence-based preventive intervention. Infant Mental Health Journal, 27 (1), 5-25
- MacMillan, H. L., Wathen, C.N., Barlow, J., Fergusson, D., Leventhal, J.M. and Taussig, N. (2009). Interventions to prevent child maltreatment and associated impairment. Lancet 373: 250-266
- Barnes, J et al (2009). Nurse-Family Partnership Programme: Implementation in England - Second Year in 10 Pilot Sites: the infancy period. London DCSF.