Family Nurse Partnership Programme
The final item of business today is a members’ business debate on motion S3M-5636, in the name of Ian McKee, on the family nurse partnership programme. The debate will be concluded without any question being put.
Motion debated,
That the Parliament congratulates NHS Lothian on being selected by the Scottish Government as a test site, fully funded for three years, for a Family Nurse Partnership programme, an intensive preventive programme for vulnerable first-time young parents that has a 30-year evidence base showing the potential for improvements in women’s ante-natal health, reductions in children’s injuries, greater intervals between births, increases in fathers’ involvement, increases in employment and earnings, reductions in the need for benefits, improvements in school readiness, reduced arrests and criminal behaviour in 15-year-olds and mothers and that eventually produces savings five times the amount of an initial investment; realises that one measure alone is not the entire answer to challenges in this field but a welcome start, and wishes the project every success.
17:09
It is well recognised that the environment around a child in the very early years has an enormous influence on his or her subsequent development and life prospects. For many children, that environment is provided by a parent, or by parents with support from family or outside agencies such as health visitors, nursery staff and the like. However, some need much more help.
Some parents are little more than children themselves. They might be on their own with no family support, low income, poor education and inadequate personal experiences of positive upbringing. I came across such parents in my previous work in general practice. It is not that they do not love or care for their children: indeed, they do, but they lack self-confidence, knowledge and all the other attributes that many of us take for granted. They find it a huge struggle to bring up a child, and some fail altogether. There have been many attempts to help such parents, but those attempts have often had limited or no success. Usually, the reason has been that efforts have been made too late, that they have been too poorly resourced and that they have lacked an evidence base. That is why I whole-heartedly welcome the introduction of a pilot scheme in Lothian—the family nurse partnership programme.
What is the difference between the programme and former interventions? The answer is simple. This one is based on three decades of extensive research in the United States by Professor David Olds—research that has been shown to be effective in three controlled trials. It is an intensive programme for supporting vulnerable young parents from early in pregnancy. The programme is provided alongside routine maternity care, and the specially trained family nurses who work in it have a close working relationship with a multitude of other services. Nurse participants, who are drawn from a wide variety of nursing backgrounds, receive about 20 days of specialist training, which allows them to focus on the social, emotional and economic context of the client’s life, with the ultimate aim of building the client’s skills and confidence to enable them to determine their own future. That requires not just professional training but time and continuity. As I said, the support must start early in pregnancy, and input must be maintained for at least two years if it is to have a chance of succeeding.
I can already hear some people saying, “Surely this is very expensive—too costly to be affordable in these difficult financial times.” My retort is, “Follow the evidence.” The United States’ experience is that there is a saving of $5 for every $1 that is invested in a family nurse programme. If we look at the statistics, we can see why. The cost of keeping a child in care in our country is about £2,500 a week, and a child with behavioural and offending problems might account for a massive £80,000 a year. Evidence from England, where such schemes are already under way, suggests that the total yearly cost for clients who complete the programme is only about £3,000.
The additional benefits that have been shown in the US include reductions in benefits claimed, increases in income and employment, greater involvement of fathers, fewer unwanted pregnancies, less child abuse, less criminality and—perhaps above all—happier children and more confident parents. For some families, the costs are recovered before the child reaches the age of five.
The pilot scheme in Edinburgh, which is funded for three years, will establish a team of six family nurses, a psychologist and administrative support to serve 150 families. The scheme will be confined to first-time teenage parents who intend to keep their babies and it will be entirely voluntary. Although the US evidence shows that the scheme there is effective, the Edinburgh initiative will be independently evaluated to see whether it works here, because our society is so different.
What are the concerns? I hope that there will be some early signs of success, but the true value of the scheme might not be fully realised for many years. How will its potential be assessed and funded? Will a three-year pilot be long enough to assess properly? England is at least two years ahead of us in family nurse partnerships, so we will get a little information on how the scheme works within the national health service family before our decision time is upon us, and that might help.
We must resist the temptation to cut corners by watering down the programme that is offered or by subcontracting the work of development and support to other agencies as part of a roll-out on the cheap. All the evidence suggests that that would be a sure way to lose most if not all of the benefits, and the outlay would still be considerable. The fact that the development work is being done under strict licence is some protection against that.
Further questions to be asked include how we can fund the immediate costs of a roll-out to all parts of Scotland and whether the health service bear all the costs when the benefits are of value to wider society.
Let us resist the temptation to regard the scheme as a panacea for all the problems of vulnerable mothers and their children. Many women would not have become mothers at such an early stage of their lives if suitable services had been available to them. Others cannot cope but cannot be helped by the scheme because of age, parity or inclination. They need help in other ways. However, the family nurse partnership programme promises well, and I commend the Scottish Government and NHS Lothian for embarking on it.
17:15
I congratulate Ian McKee on securing the debate on a subject that has featured in many of the health debates that we have held as a matter of course in Parliament over the past few months. The initiative in NHS Lothian has been alluded to on previous occasions by Ian McKee and Malcolm Chisholm.
Many members will have met or heard speak Dr Philip Wilson. When he gave evidence to the Health and Sport Committee on child and adolescent mental health services, he said:
“there has been an enormous blossoming in the evidence ... on ways of identifying early in life the children who are going to follow a problematic and painful trajectory ... there has been a big increase in the evidence ... on what works to stop the bad things happening. At a policy level, there has been substantial movement towards an emphasis on the very early years.”—[Official Report, Health and Sport Committee, 25 March 2009; c 1728.]
That inquiry made it patently clear how fundamental the early years are to an individual’s development and their mental health later in life. A vast range of variables, including mental health, sexual health, education, involvement in crime and employability can be shaped in the earliest years of a child’s life.
David Olds pioneered much of the work that underpins the family nurse partnership in the United States. It is important to bear in mind the reservations of Philip Wilson and others, who believe that we cannot look to the way in which the family nurse partnership has operated in the United States, where health services are such that it has operated almost in a vacuum, away from any other service provision. That is not the case in the United Kingdom, where we have had an active health-visitor service that has performed much of that function.
If one looks at the experience of the pilot in England, it is clear that a pilot can almost be an obstacle to the progress of a wider service. By definition, a pilot involves putting together a unit that must try to perform functions to certain targets. The pilot in England failed to meet the recruitment target of enrolling 60 per cent of pregnant women by 16 weeks’ gestation. In addition, there was quite a fall-off—only 53 per cent of expected visits were carried out.
Nonetheless, I welcome the Lothian pilot. It ties in strongly with the direction in which Conservative thinking has moved. I have raised—for no political advantage, as I hope members will accept—health visiting, particularly in Bridgeton and Possil, repeatedly in Parliament. I fear that the changes that we have made in the structure of health visiting have devalued the perception of the profession among the dedicated people who have worked in it, to the extent that many of them are now leaving it and there is a significant shortfall in the number of experienced people who wish to go into it. That is reflected in communities in which there are considerable inequalities and disadvantages, where the very issues that we seek to address through the family nurse partnership programme exist. Our inability to bring people in to provide and maintain such concentrated involvement is an issue.
Scottish Conservatives believe that although the pilot in Lothian is of value, we need to look beyond it to a universal health-visiting service. I know that the minister will say that, to a degree, such a service already exists, but it is not involved in the development and welfare of children over a two, three or even five-year period to the extent that it can identify the issues that the Lothian programme is to identify. If we are to put together a preventive health service that avoids many of the problems that we pay for subsequently, not just in the waste of human talent but, at great expense, in our health service, we need to find a way of providing that universal service across a wider spectrum.
As a party, we would have put more money into health visiting, to ensure not just that a universal service was retained, but that in areas of inequality we could address matters by having more health visitors who perform the role that the family nurse partnership fulfils.
I look forward to progression of the pilot. I hope that if evidence starts to emerge from developments in England and elsewhere, we can consider providing something near to a national framework for health visiting in Scotland, because I am not sure that it is the right way forward for health boards to pursue different strategies. I hope that we will be able to focus our attention on a community that could benefit enormously from that attention in the long term. It is about developing a talent that is currently being wasted by giving families support that may prevent subsequent breakdown and by giving young people a start that prevents their descent into crime, and other problems that follow from that. If we can do that, we will tackle inequalities in the health service and introduce a much more rewarding health-visiting service for the people who are served by it and the people who work in it.
17:20
I welcome the debate. I proposed an amendment to the motion to indicate that the family nurse partnership is part of the comprehensive consideration of child issues by the Prime Minister’s Office under Tony Blair. I hope that the Scottish scheme builds on the successes that are being achieved in the English scheme. As Ian McKee said, the scheme was inspired by a similar approach, over many years, by Professor David Olds. In America at least, the results have been impressive.
In 2006, the UK Government announced that it would pilot family nurse partnerships in 10 sites throughout England. Applications were invited from primary care trusts, and local authorities were involved in providing continuing funding and support until the children were 24 months old. That partnership is an important feature that I am not sure is reflected in the Scottish pilot. I do not know whether it is entirely funded by the national health service, or by Government, and whether that will be the case for future waves.
The evaluation of the original pilots in England showed positive outcomes, not only for the pregnant women but for their families and the nurses involved. Those who benefited said that in the beginning they thought that the nurse might be nosy or judgmental, but that was not the case, and most got on well with their nurses. Importantly, we found that the fathers were often involved to a greater extent than might otherwise have been the case.
It is important for the scheme that young parents are able to trust those who are giving them advice. There were some problems with workload and the burden of lots of paperwork. Paperwork is a feature of pilots, and I hope that that will not occur when this pilot is rolled out, so we should watch that closely.
In England, the scheme has progressed and is now into phase 2, with waves 2, 3 and 4, of 20 sites each, and a planned full roll-out from 2011. As Ian McKee said, England is really going for it—it is not just a one-off pilot. Whether it will continue under the new Conservative-Lib Dem coalition remains to be seen. Scotland appears to be slower, although the minister may be able to give us more information.
I have a number of concerns about the Lothian pilot. My colleague Marlyn Glen has asked a number of parliamentary questions about it. I support and commend the project but it has a top-heavy feel to it. There is a 16 to 20-hour clinical lead, a full-time project supervisor and a full-time lead nurse supervisor—I am not sure how many of those are engaged on the front line. Sometimes, such a top-heavy approach is needed in pilots; hopefully it would not be needed in a roll-out. Nevertheless, if we add on six nurses and an administrator, we end up with a cost of £1.6 million for 150 families. Will that be sustainable if the pilot is successful? As Dr McKee said, it is an important scheme.
I am concerned about the selection process in the Lothian scheme. It applies to mothers under 18, whereas throughout the UK most schemes have been for mothers under 20, although I gather that some have gone up to 23. It is probably acceptable that it applies only to first-time mothers. However, although the group that is being selected in the Lothian pilot is a vulnerable one, other measures of deprivation are identified in research from the growing up in Scotland project—which has published interesting material today—that surely should have been among the criteria. The current criteria include the single eligibility clause, which I presume is a mistake in the notes from Lothian; being under 18; and being a first-time mother. However, in identifying those who might benefit, other measures of deprivation should have been included, such as a parent having no work, poor housing, no qualifications, long-term illness or disability, income below 60 per cent of the median, and an inability to provide some items of clothing or food. I am also concerned about the failure to identify one issue in particular: poor mental health in the mother, beyond the normal period for diagnosis of post-natal depression.
It is important to know whether this family nurse partnership is linking to Home-Start, sure start and to child and family centres—in other words, the developments that the previous Administration focused on in order to try to create improvement among vulnerable families. As far as I am aware, the Scottish National Party abandoned Labour’s pilot scheme on nursery education for vulnerable two-year-olds. What is the exit strategy for these families? They will obviously require continuing support.
How does the family nurse partnership link to third-sector support, during and after the period that it is concerned with? How does it supplant or work with midwifery services, particularly in Lothian, which has a specialist service for people with addictions, who form another significant vulnerable group?
What other projects for vulnerable groups are being trialled in Scotland? Are we trialling the family pathfinder projects from England, the family intervention project, the family group conferencing project or multisystem family therapy? If we put all our eggs in this one basket—which is a pretty expensive basket—we may have problems.
I commend Jackson Carlaw, because the fundamental issue before us involves the question of how we can move from universal health visiting, with screening, to providing actual support for vulnerable families. The previous Administration did not solve that problem and I do not believe that the current one has done so, either. The problem is difficult to deal with in a time of economic restraint, but we must make a serious attempt at solving it.
17:26
Like others, I congratulate my colleague and old friend, Dr McKee, on securing this debate. He rightly pointed out that the family nurse partnership has been well researched over a period of 30 years in the United States. As I understand it, it is somewhat inspired by the system of health visitors in this country. I know that the valuable role of health visitors is appreciated by members throughout the chamber. The way ahead for health visitors has been the subject of debate and will no doubt continue to be so.
It is, of course, good news that the family nurse partnership is fully funded by the Scottish Government for three years. I do not doubt that that is money that is well spent on vulnerable first-time parents.
As the member for Livingston, I am acutely aware of the high number of young parents in my constituency. I hasten to add that I do not see that as a bad thing—I do not consider the terms “young parent” and “young mother” to be pejorative. Some 38 per cent of 16 to 24-year-olds in West Lothian have one child or more, whereas the national average for that age range, according to the most recent census, is 32 per cent. Although the figure for West Lothian does not represent huge numbers of people, I note that the rate of teenage pregnancy in pockets of deprivation in my constituency can be three or even 10 times the average.
Ian McKee’s motion points out that one measure alone will not provide the entire answer to the challenge of working with young vulnerable parents. Young parents do not always access services, which often are not designed for them. Further, public policy is often designed to deter young people from becoming parents too soon, although ironically it has little to say when they do.
I am pleased to say that there is a history of good work with parents in West Lothian. The Broxburn family centre has done much pioneering work, combining parenting input with educational input, and the sure start programme has worked well with the department of adolescent and child psychiatry and the department of psychological services at St John’s hospital.
I am aware that Barnardo’s Scotland has an excellent test programme called you first. One of the two test sites is in Blackburn in West Lothian, just outside my constituency. Crucially, the you first programme, like the family nurse partnership, enshrines the belief that young parents are part of the solution and not part of the problem. They are a resource with whom organisations should work in partnership. All the evidence shows that the relationships that the skilled workers—whether they are nurses or social workers—form with the participants, and the skills that they deploy, are often more important in achieving outcomes than the course content.
The you first test project has had tremendous outcomes. All the participants are on course to achieve qualifications. There are reports that participants have developed better relationships with their children, and 80 per cent of the parents are receiving the benefits to which they are entitled. They have bank accounts, and they have been put in touch with the local credit union.
A general point about the evaluation of programmes such as the family nurse partnership and the you first programme is that we should evaluate not only the outcomes for parents but the outcomes for children. The key objective of all services that work with parents is to improve the life chances of children.
One small caveat to supporting such initiatives is that, as Richard Simpson said, we have to guard against endless pilots. We need to ensure good integration and co-ordination of services, whether those are statutory services, the health service or services in the voluntary sector. We need to avoid duplication, because that is important in these difficult financial times, and because we need to ensure that we have a good geographical and equitable distribution of services.
It is always worth making the point that parenting, and ensuring that children get the best parenting possible, is everybody’s business: every department of Government, local government and the health service.
17:32
I congratulate Ian McKee on lodging this important motion. I also congratulate NHS Lothian and the Scottish Government on their willingness to participate in and support such an exciting project. They have, to their credit, been very open-minded and willing to learn from other countries.
Many people will say that, given the current financial difficulties, it is not the right time to spend extra money on new initiatives. However, it is important that we examine the evidence and do not take a short-term view of public expenditure. The issue has come up regularly in the Finance Committee’s current work on budget scrutiny, and we have heard a lot of evidence that investment in the early years will, in the long run, save a lot of money.
The work of Professor David Olds presents a wealth of evidence. For example, follow-up studies in the United States indicated that children in vulnerable families who received intensive home visiting from health visitors up to the age of two were, by the age of 15, half as likely to have psychological problems and half as likely to have been involved in the criminal justice system as similar children who were not in the programme. We simply cannot afford to ignore such powerful evidence. As we enter our budget discussions in the next few months, we need to think about the long term and recognise that investment in the early years benefits society in the long term.
The key words are “vulnerable families”. People may question whether the full spread of vulnerable families have been involved in the Lothian pilot. It is a pilot, so obviously it involves a limited number of people, but we recognise that teenage parents are only one part of the vulnerable category—many others could benefit from the programme. It will always be difficult to decide who participates, but the principle of giving additional, intensive support to vulnerable families is absolutely right. We will see from the evaluation of the Lothian pilot exactly how effective it is, but we can see from the experience in the US and England that the outcome is likely to be positive.
It is a great credit to the Government and NHS Lothian that they have been willing to get involved in this work. Obviously, I will take a particular interest in it as an MSP representing Edinburgh, and no doubt some of my constituents will benefit from it. We will all examine carefully this work as it evolves and the evaluation of it. We should be prepared to learn the lessons from it and, despite the difficult times that we are in with regard to public expenditure, to commit resources to the early years, because the future of society depends on that.
17:35
I, too, welcome Ian McKee’s motion and congratulate him on securing the debate. It has been constructive and many important points have been made, not least Malcolm Chisholm’s point about how important investment in the early years is—I whole-heartedly agree.
I am pleased to say that, after an extremely successful recruitment process, which saw more than 60 community nurses apply, the first family nurse partnership team in Scotland has been established. All seven posts have been filled and the team is located in the Craigmillar area of Edinburgh.
The team is now in the process of recruiting first-time pregnant teenagers, who must be under the age of 19. I acknowledge, of course, that there are many other vulnerable parents, but it is right, in a pilot, to focus, here on first-time pregnant teenagers from the Edinburgh community health partnership area.
The programme is licensed by the pioneer of this work, Professor David Olds of the University of Colorado, and it has fidelity requirements to ensure that the potential gains, seen over a 25-year period in the USA, are realised. Ian McKee made the important point that the real benefits take some time to be fully realised, but there are also measurable benefits in the shorter to medium term. We hope in the Scottish model to emulate the success experienced in America, in particular by developing the self-confidence of our young parents to be the parents that they want to be and can be.
The seven family health nurses have started their mandatory masters level education and training, which is an important part of the preparation process. The crux of the success of the programme is the intense strength-based and therapeutic relationship between nurse and client. To achieve that, nurses need to feel supported in their day-to-day work with families, and they will be supported by a psychologist.
The target level of recruitment to the programme is set at at least 75 per cent of all teenagers who meet the eligibility criteria and we are currently reaching 82 per cent of such teenagers. Those young people do not feel stigmatised, as the programme is being offered universally, on an entitlement basis, to all pregnant teenagers who are becoming parents for the first time.
The programme is offered to all teenagers who meet the criteria, irrespective of where they live or their family circumstances. Early reports show us how important that is. Of the few who have declined the programme, half report feeling well supported by family and friends. We hope to recruit a total of 145 teenagers before the autumn and will support them and their families until their child reaches two years of age.
The family nurse partnership team has worked closely with colleagues in universal services in Edinburgh, particularly in public health nursing, health visiting and maternity services and with other health and social care professionals, including general practitioners and those in social work services. They are creating effective referral pathways to ensure that they reach these mothers-to-be during the key window of opportunity that occurs during a first pregnancy. I have heard about numerous examples of good practice around information sharing, particularly between the FNP team and housing colleagues, which have allowed the right practitioner to intervene at the right time to maximise support for the young mother in advance of the arrival of a new baby. That exemplifies the principles of getting it right for every child, in which a joint approach with a clearly identified lead professional can make a real difference to a family.
In Scotland in 2008, more than 3,000 young teenagers would have been eligible for the family nurse partnership programme, with 70 per cent of them being in the lowest deprivation quintiles. Offering the programme to all teenagers who meet the current eligibility criteria would see us supporting the most vulnerable of our future young parents and offering the best possible start to their children.
As members have said, we need to proceed with caution and learn from the family nurse partnership implementation elsewhere, as well as in Edinburgh. The randomised control trial across 18 sites in England will shape the future of the programme in Europe and will provide us with evidence of the overall benefits, including cost benefits, as the programme is delivered in Scotland. Our evaluation, which is to report in three years, will focus on the transferability of the model into the Scottish context.
Richard Simpson implied that somehow Scotland has been slow in introducing the family nurse partnership. I point out that, in England, the implementation of the programme started in March 2007, but of course the discussions and planning went back to 2006 and before. I have not found evidence of movements at that time on the issue here in Scotland, although they might well have been planned—we do not know. However, when we came into Government in May 2007, we felt that the programme was worth while and that Scotland should trial the system.
Areas of learning have already been identified that could be transferable to all disciplines that support families with children in the early years. Young people have described how they feel respected by the nurses and have said that, by considering their aspirations, hopes and desires, the programme helps them to see a positive future as parents. Although the approach of developing self-efficacy in young people is not new, it has potentially far-reaching benefits when working with that client group.
The potential longer-term gains from the work—such as a decreased number of subsequent pregnancies, longer intervals between pregnancies, children with better school readiness, decreased involvement in crime and healthier mothers and children—will take longer to evaluate, but we know that those key issues, along with health behaviours, are linked to social deprivation and poverty. We must continue to address the early risk factors to improve outcomes. Angela Constance made the point that the programme is not a panacea and that we need to work on other issues.
Jackson Carlaw expressed concerns about how the family nurse partnership relates to the wider pool of nurses and health visitors. We know from Professor David Hall’s work that the average health visitor input into families such as those of first-time teenage parents is 10 times the input into other families in the case load. I have asked for the evaluation of the family nurse partnership in Scotland to include a review of how the programme impacts on the work of colleagues who support young parents, particularly in universal services. I hope that that reassures Jackson Carlaw that we are aware of the issues that he raises.
It is early days in the testing of the new model, but the signs are promising. We are reassured by the family nurses in the team, GPs, colleagues in universal services and those whom I have spoken to at recent conferences that the approach makes sense. We now need to work towards measuring the effectiveness of the programme and sharing the learning with others on what we believe is an effective way of supporting young parents and their children to gain a better start in life.
Meeting closed at 17:43.