The next item of business is a members’ business debate on motion S4M-13494, in the name of Jim Eadie, on the fifth anniversary of the family nurse partnership programme in NHS Lothian. The debate will be concluded without any question being put.
Motion debated,
That the Parliament congratulates Edinburgh on becoming what it believes is the first city in the world to offer the Family Nurse Partnership programme to all eligible women in its fifth anniversary year; understands that the pilot programme, which was launched in NHS Lothian in 2010, has provided support and advice to 660 mothers in Lothian; welcomes confirmation that the resources and staffing are now in place for every eligible young mother in Edinburgh to be offered a place on the programme; further understands that the programme is an intensive, preventive, one-to-one home visiting programme for young, first-time mothers from early pregnancy until their child reaches the age of two and was developed in the United States by Professor David Olds; supports its main aims of improving pregnancy outcomes, child health and development and the economic self-sufficiency of the family; considers that the scheme has been such a success that it now operates across seven NHS board areas, Lothian, Tayside, Fife, Greater Glasgow and Clyde, Ayrshire and Arran, Forth Valley and Lanarkshire and benefits over 2,000 mothers across Scotland; welcomes plans for expansion into Borders and Grampian NHS board areas later in 2015, and commends what it sees as the valuable work undertaken by Family Nurse Partnerships in Lothian and across Scotland.
12:35
It is a real privilege for me to be able to bring this debate to the chamber. I am most grateful to all the members who have supported the motion in my name.
The debate is an opportunity to recognise the innovative work that has been undertaken by family nurse partnerships across Scotland. As an Edinburgh MSP, I am particularly pleased to recognise the fact that Edinburgh has become the first city in the world to offer on a sustained basis the family nurse partnership programme to all eligible women. That means that every first-time mum in our capital city who is aged 19 or under will benefit from the programme. In total, more than 2,000 mothers have already benefited from it—more than 600 of them here in Lothian.
The service began as a pilot project in January 2010 and has made a real and lasting impact—so much so that it is now being rolled out across the whole of Scotland. Teams are already in place in the Lothian, Tayside, Fife, Greater Glasgow and Clyde, Ayrshire and Arran, Forth Valley and Lanarkshire health board areas, and there are plans to extend coverage to the Borders and Grampian later this year.
I thank the Scottish Government—the Minister for Public health as well as the current and previous First Ministers—for the political leadership that it has shown. Sometimes leadership is required to say to the sceptical voices in the civil service and the vested interests, “This is the direction in which we are going to go and this is what needs to happen.”
I also thank NHS Lothian—in particular, its director of nursing, Melanie Johnson—for the clinical leadership and commitment that it has shown in the pilot project, which has proved to be so successful. Most of all, I pay tribute to the nurses, the highly skilled and empathetic healthcare professionals and the young mums who have made the programme work.
The family nurse partnership programme is an intensive preventative one-to-one home-visiting programme for young first-time mothers from early pregnancy until their child reaches the age of two. Mums are visited by a specially trained nurse every week or two weeks during pregnancy and throughout the first two years of their baby’s life.
The programme was first developed in the United States by Professor David Olds, who is a professor of paediatrics at the University of Colorado. It is delivered in this country under licence, and it has three main aims: to improve pregnancy outcomes; to improve child health and development; and to promote the economic self-sufficiency of the family. It aims to introduce a new approach to nursing that involves working with the parent to help them to build up their own skills and resources to parent their child well, and to think about their own aspirations for the future. The programme is intended to offer targeted intervention in addition to Scotland’s universal health visiting services.
It is important to put the family nurse partnership programme into its wider strategic and policy context. It is part of a wider approach that recognises the importance of targeted interventions—in particular, in the early years of life. In the United States, there has been the development of the concept of the social womb—the environment that a baby experiences after birth. J Ronald Lally, who is co-director of the centre for child and family studies at WestEd in the USA, has stated:
“Be it at home or in childcare what happens during infancy is too eventful to leave to chance.”
That wider approach also requires paid parental leave so that parents can spend critical bonding time with their baby, and it requires the provision of high-quality and affordable childcare. It sits alongside and complements well-resourced universal provision of health visitors, to which the Government is committed.
However, we should not lose sight of the unique and innovative contribution that family nurse partnerships can make. The Scottish Government’s own data clearly show that women aged under 20 living in the most deprived areas—the target client group for the partnership—are about 10 times more likely to have a child than women of the same age who live in the least deprived areas.
We also know that other problems that impact negatively on the wellbeing of mums and babies are more prevalent in areas of multiple deprivation. For example, nearly 31 per cent of women in the most deprived areas self-report as smokers at the time of their first antenatal visit, compared to just 6 per cent of women in the least deprived areas. That is a stark reminder of why the approach that is embodied in the family nurse partnership programme is necessary in order to target vulnerable mums and babies and offer them the intensive support that they need.
When we take the time to examine the benefits of the programme, it becomes clear why the Scottish Government and health boards are right to make that investment. Nurses support mums to make positive choices in areas such as child development, preventative health measures, parenting skills and breastfeeding, and offer better diet information and practical support on education and employment opportunities. All that leads to improved pregnancy outcomes and improved child health and development.
I refer to an article that appeared in The Observer in March of this year. It will not be possible for me to quote it extensively, but I point out that the journalist spent three months in Manchester and Portsmouth observing the impact of family nurse partnerships on the women and babies who participated. She concluded that she witnessed
“how this extraordinary intervention achieves little short of miracles.”
The personal story in the article that stands out is that of a young woman, Sarah—not her real name—whose father had hanged himself when she was nine and whose mother had died of an AIDS-related disease when she was 13. She had been in and out of care, had a badly scarred face from a dog bite and her boyfriend—a user of drugs—was in prison. Her nurse said that as a result of the programme:
“She had twin girls; she breastfed. She dumped the boyfriend. She had her scars fixed, so her self-esteem has risen, she is at college and has a part-time job and her own tenancy. Her two little girls are doing so well. We tell our girls again and again: ‘You can be different if you choose to be.’”
As well as considering those anecdotal personal testimonies, it is important to observe that the programme is underpinned and supported by extensive research. That includes the findings of the three US-based randomised controlled trials, drawing on the experience of the programme over 30 years. Here in Scotland there have been four detailed evaluation reports that explored the experience of delivering the family nurse partnership in the first Scottish test site in NHS Lothian.
In addition, it will be important to understand in a United Kingdom context what added value family nurse partnerships deliver over and above universal service provision, where the national health service already offers midwifery and health visiting support. The randomised controlled trial—the building blocks trial—which is evaluating the family nurse partnership programme in England, will be instructive in that regard.
There is growing evidence from the United States and England of the real benefits of the programme. There is evidence from an evaluation that was carried out in England by the University of Nottingham of the benefits of early intervention for fathers who are involved in a home-visit service that is delivered by the family nurse partnership. The evaluation states:
“The ‘early’ nature of the help was crucial to its success because of how it so effectively tapped into the men’s redefinition of themselves as caring fathers during pregnancy and following the birth.”
We should celebrate family nurse partnerships—we should invest in them, we should continue to evaluate their impact and we should roll them out across the country. This is an investment like no other. It is one that is not only changing lives but is transforming the lives of young mums and babies for this and future generations, and is giving vulnerable children in some of our most deprived communities the best start in life and the greatest chance to succeed as they grow and develop as adults. What better legacy could there be for our society?
12:44
I congratulate Jim Eadie on securing the debate. I also congratulate NHS Lothian because Edinburgh is, I think, the first city in the world to offer the family nurse partnership programme to all eligible mothers—in this case, teenage mothers.
The programme started five years ago. It was, in a sense, part of a wider movement towards focusing on investment in the early years as part of the preventative spend agenda. The idea is that, by investing a lot of money in the early years, some of the problems that children face growing up and later in life will be avoided.
As Jim Eadie said, the family nurse partnership programme is based on a programme from America, which is well-evidenced by randomised controlled trials. We know from Professor Olds and the evaluation in America that the programme’s outcomes include better pregnancies, improved child health and development, and improved parental life course. Of course, that does not automatically mean that the outcomes in Scotland would be the same. For a start, we have a national health service: clearly, there is nothing like that in America. Therefore, it is important that we do separate evaluations in Scotland. I have read NHS Lothian’s latest evaluation, and I will obviously draw on that in my speech.
Like Jim Eadie, I am very enthusiastic about the programme. However, others have been more sceptical. For example, I am told that a recent parliamentary question suggested that breastfeeding rates for mothers on the programme were 5 per cent only. We should not be so starry-eyed that we do not focus on areas where the outcomes are perhaps not so outstanding. However, in general, I am positive about the programme.
The programme appears to be tightly controlled and prescribed—everyone must follow the procedures and protocols that were laid out by the programme’s founders. However, in reading the evaluation, I see that, in a sense, part of the prescription is to be flexible; there is flexibility to meet individual clients’ needs.
The training of the nurses is important. I was struck and impressed by mothers being involved in the selection of the nurses. The key issue seems to be the quality of the relationship between the nurse and the mother, and the consistency of that relationship over a significant period, with regular visits. It seems to be a non-judgmental approach. The nurse can say to the mother, “Take this on board if you want to.” In addition, the small attrition rates suggest that the programme is valued highly by the mothers who receive it.
The basic idea is to give mothers the support that they need, to help children to get the best possible start in life and to prevent the problems that might otherwise arise. We should not just look at the programme from a public expenditure point of view, because the programme is quite expensive in the short run. However, the belief in America and the evidence from there are that it saves money down the line, because some of the children do not have the problems in later life that they might otherwise have had.
The whole programme is underpinned by attachment theory and recognition of the mothers’ strengths, which is a part of the assets-based approach that we sometimes hear about.
The evidence is that the programme is a good one. The Scottish Government has been doing some worth while and innovative work on the early years. Alongside the family nurse partnership, we could look at the early years collaborative. Sometimes, those are set against each other as alternative ways of pursuing a preventative spend agenda. I prefer to see them as complementary initiatives. Indeed, I certainly do not see any contradiction between them.
I welcome what has happened here in my city, and I am glad that the programme has been extended throughout Scotland. Clearly, we must keep on evaluating the programme. If there are weaknesses in the outcomes, we must address those. I commend all the work that has been done here in Edinburgh and I commend the Scottish Government for supporting the programme.
12:49
I thank Jim Eadie for securing a debate on this important subject. The topic is highly important in its own right but, in many ways, it is symbolic of the whole area of preventative spend, which I will concentrate on.
I must say that, as a Glasgow MSP, I do not always support motions that start with the words:
“That the Parliament congratulates Edinburgh”.
However, I will make an exception today.
We can come at the subject from different angles and take, say, a health or Edinburgh focus on it. I will take a finance angle, not least because the Finance Committee, of which I am a member, has spent a considerable amount of time thinking about preventative spending. Whenever we discuss the subject, we find that family nurse partnerships are one of the most common examples that are given. Indeed, this was the major topic at a recent round-table event at the University of Edinburgh in which the committee took part.
If we as a Parliament and as a country are serious about spending money in the earlier years to save it later, family nurse partnerships are exactly the kind of thing that we need to be doing. As the preceding two speakers made clear, if a child gets a better start in life, they will not be so far behind when they start school, they are less likely to be in trouble in their teenage years and they are more likely to do well in later life. I think that we are all signed up to the concept; I certainly sense a lot of agreement on the issue when we MSPs are in smaller groups at committee meetings and are, perhaps, behaving more sensibly.
As I understand it, the FNP programme has tightly defined rules—albeit that, as we have heard, it has a certain flexibility. It deals with a specific group of young mothers and has been well analysed, especially in the United States.
One of the challenges that we face is whether we can move more resources into the early years—whether that means FNPs or other programmes—because that means moving resources away from more reactive forms of expenditure. For example, in the health field, we might think of moving resources away from hospitals and into community and preventative programmes. That is where it becomes more difficult to gain consensus, especially when we get together in the combative atmosphere of the chamber. Are we really happy for some hospitals to be closed to free up resources for young families in the community? Are we happy to let accident and emergency waiting times rise to let general practitioners spend more time with their patients?
I thank the Royal College of Nursing for its briefing for today’s debate, in which it, too, highlights the tension on where resources should go and refers in particular to resources, staffing and the professional back-up that is required for the FNP programme. The RCN is particularly concerned that the wider health visiting service is stretched and competing for the same resources. The question that it raises is valid. In the final paragraph of its briefing, it says:
“So that no children fall through the gaps, the RCN believes that the Scottish Government should ensure Scotland has adequate health visitors, in addition to FNP nurses.”
As a result, we should be putting more emphasis on FNP nurses and health visitors, given that both are based very much in the community.
As for where the resources would come from, I presume that they would come from reducing resources for hospitals. I note that in the statement entitled “Building a more sustainable NHS in Scotland: Health professions lead the call for action”, which has already been debated in the chamber, the RCN said:
“the focus has remained firmly on the traditional model of hospitals as the mainstay of the health service. This needs to change.”
As the motion says, we congratulate Edinburgh and commend the valuable work undertaken by family nurse partnerships in Lothian and across Scotland, and I very much hope that we can continue building on this example by disinvesting from our more reactive services and investing more at the preventative end.
I call Jackson Carlaw, after whom we will move to the minister for her closing speech.
12:53
I hope to be commendably brief, Presiding Officer.
Although I support Jim Eadie’s motion on family nurse partnerships, I will raise some concerns about the consequences—John Mason expressed views about that, which I very much share. I support the family nurse partnership because of its focus on the preventative agenda; after all, all the evidence suggests that, if we are to make savings in our health service to ensure that it can cope with the wider challenges that we know it will face with an ageing population, we have to become much more successful in our preventative strategy. Although Mr Eadie is right about family nurse partnerships—the programme’s track record in the United States, which Malcolm Chisholm referred to, and in England shows that it can have dramatic results—it is neatly targeted and focused on young mothers under the age of 19, and it has a consequence for the wider health visiting strategy.
The Scottish Conservatives have expressed concern about our approach to health visiting. Each of our 14 health boards can determine its approach to that and the resource that it puts towards it. We moved away from a nationally GP-attached service to one that works in teams. The consequence was that the skill set that previously existed in individual health services, with health visitors being attached to GP practices, was slightly diminished by a range of skill sets in the broader teams that were then brought to bear.
Some of those skilled health visitors have now applied to be family nurse partnership specialists, which has further diminished skill sets in the health visiting service. Moreover, more than 40 per cent of the family nurse partnership staff are aged 50 or over, and a significant age issue is arising in national health visiting as well.
The Scottish Conservatives support family nurse partnerships. We believe that such targeted and focused assistance to the group involved is important. However, we also believe in a universal GP-attached health visiting service that takes children through to the age of seven, because there is a lot of compelling evidence to suggest that trends that develop in young children beyond the age of two—from the age of three and beyond—that lead to obesity, potential future addictions or even offending rates, can be dealt with through such intervention and support.
We believe in a universal service so that all children have access to it, but we also believe that there should be a concentration on areas with high levels of health inequality and deprivation, because that is where the service is needed most. There are young mothers who are vulnerable, deprived and over the age of 19, and they do not have the benefit of a family nurse partnership, but they need the support of a well resourced health visiting service if we are to succeed in the much wider spectrum of prevention in young persons’ issues.
I fully support the family nurse partnership programme and would like it to be rolled out further but, in the wider debate that we are having—I hope that the minister accepts that this is not a criticism but part of what we hope is a constructive approach to the shape of the health service going forward—I do not necessarily believe that this is, as John Mason said, a question of hospitals closing down. The whole point about a health prevention strategy is that we can—with a different model of GP facilities and with a successful health prevention strategy—reduce the incidence of people presenting at A and E and potentially the cost burden to the health service of type 2 diabetes, for example, because we could prevent that with a better approach to young people’s health and by avoiding issues of obesity.
I hope that the minister accepts my remarks in the spirit in which they are meant. I am concerned and I feel that, in the next parliamentary session, as we look at how this new model of healthcare develops, we need to roll out family nurse partnerships, which I believe are successful, in conjunction with a wider availability of service to a much wider target group of people, universally, and particularly where vulnerabilities and health inequalities exist.
12:58
I am delighted to be asked to congratulate NHS Lothian on Edinburgh becoming the first city in the world to offer the family nurse partnership programme to all eligible women in the programme’s fifth anniversary year. I welcome the speeches that members have made and I thank Jim Eadie for lodging the motion.
In 2010, NHS Lothian was the first board in Scotland to deliver the programme. It has been clear in its commitment to the programme from the outset. Evidence from the evaluation that was carried out over three years demonstrated that the programme could be implemented with fidelity to the original research model.
NHS Lothian has worked closely with the Scottish Government, using a co-production model, to ensure that learning is embedded in wider policy rather than just in the programme. The lessons that can be learned from the family nurse partnership are being applied in the wider health visiting community. Learning has been shared with other universal services, including maternity services and health visiting, and I commend them for their continuing commitment to the programme.
The commitment has been demonstrated further by expansion to other parts of NHS Lothian, including West Lothian, East Lothian and Midlothian, which will also have the opportunity to benefit from the programme. There are also the other health boards that Jim Eadie mentioned. The programme has started in NHS Grampian and will start in the Borders later this year, so it will cover 10 boards.
This is the first time that the Scottish Government has implemented a licensed, evidence-based programme at scale. Further expansion of the programme has to be agreed with the licence provider, Professor Olds, to maintain the quality of the implementation. The programme’s success so far has been demonstrated through the recruitment and retention of clients, as well as the dedication of the nursing teams that support them. NHS Lothian has an average uptake of 81 per cent, with only 9.6 per cent leaving the programme before their child reaches the age of two. That is well within the fidelity targets that are set in the licence, and that has been maintained throughout the implementation.
The achievement was recognised at the recent event that the First Minister hosted at Edinburgh castle to celebrate with NHS Lothian and bring a message of continuing support from Professor Olds. I was delighted to have the opportunity to attend that event and was struck by the family part of it. That involved not just mothers and their children; partners, boyfriends and husbands were also really enthusiastic and involved in the upbringing of their children. I was struck that their relationships with the nurse partnership were strong. NHS Lothian’s experience and learning have been used to inform how the programme can be rolled out across Scotland and how other health services can use it.
In her former role as the cabinet secretary for health, the First Minister visited a clinic in Harlem, New York, in April 2009, where she first recognised the strength of the programme’s evidence base and how it could contribute to giving all our children the best start in life. The programme supports first-time young mothers from early pregnancy until the child reaches two and it aims to improve maternal and birth outcomes, child health and development, and the family’s economic self-sufficiency. We have also noted a reduction in the number of children’s injuries; less neglect and abuse; and less criminal behaviour in other children and mothers. The investment is showing wider dividends.
The Scottish Government has invested £15.5 million in the programme since 2010. That has allowed dedicated nursing teams to be put in place in nine health boards. I stress again that the family nurse partnership teams are an addition to the existing community nursing workforce, which supports families who do not receive the family nurse partnership programme. We are not taking away from existing services.
The investment has also supported the infrastructure in NHS boards to allow the programme to be supported in the local context. An emphasis is placed on data collection at each visit, and the data is used to inform continuous quality improvement at each level of the programme, whether that be nurse-client, team or NHS board.
The sub-group of the population that is served by the family nurse partnership programme was recognised as a vulnerable group in the National Institute for Health and Care Excellence guidance on pregnancy and complex social factors that was published in 2010. It recognised that young women under the age of 20 should be supported through the provision of tailored advice and support that recognises their specific needs. The family nurse partnership programme goes further than that; it also recognises the strengths in that population and where there are opportunities to work with them to help them to make good choices for them and their children.
The group’s vulnerabilities must not be underestimated. According to the most recent Information Services Division teenage pregnancy report, which was published in June 2014, those who are most deprived are 4.6 times more likely to have a teenage pregnancy. The report states that, in the group of under-20s from the most deprived areas, the rate of those who go on to have their babies is almost 12 times greater than that in the least deprived areas. We also know that levels of poor health behaviours, such as smoking, are highest in that group.
The strength of the programme is that it has generated transformational change in the partner organisations outwith the national health service—particularly in housing—and helped them to recognise how to realign their services to meet the particular needs of young mothers and their families. That insightful learning was first gathered by NHS Lothian and has led to a much greater understanding by all services of what it takes to support the population group well. NHS Lothian has provided guidance and support to the other NHS boards to help inform them of how to work in an integrated way with other service providers who might not immediately recognise the importance of their role.
I recognise the achievements of nurses and families from the NHS Lothian area in successfully implementing a social intervention as complex as the family nurse partnership programme.
I thank all the members who took part in this important debate.
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