The Family Nurse Partnership (FNP) aims to improve the life chances of first-time young parents and their children by breaking the cycle of disadvantage. Lambeth’s FNP team is part of the innovative ADAPT project (accelerated design and programme testing) to rapidly adapt and test the programme, focusing in Lambeth on clinical adaptations which support the development of healthy relationships and reducing intimate partner violence.
FNP is now commissioned across England by local authorities. It is currently available in about half of local authorities in England.
Within Lambeth the service is commissioned by the local clinical commissioning group. In addition some of the service is funded by LEAP (Lambeth Early Action Partnership). This has come from financial support from the Big Lottery, known as A Better Start.
The local governance of FNP is usually delivered through an FNP board, which is chaired by the local authority public health commissioner and includes additional council and health representatives such as maternity leads, leads for children’s services, etc. In addition, the FNP National Unit support sites and commissioners, ensuring strong clinical practice and quality improvement within the programme, and introducing innovations that can benefit FNP and wider work with vulnerable families.
FNP aims to improve the life chances of first-time young parents and their children by breaking the cycle of disadvantage:
- to support mothers to build self-efficacy, helping them to get back into education, employment or training
- to improve child health and development (eg school readiness), including breastfeeding, nutrition, managing minor illness and reducing accidents
- to identify and manage safeguarding issues quickly and effectively
- to support the transition to parenthood
- to address maternal mental health issues
- to deliver the Healthy Child Programme
- to ensure young parents access and engage with other local services
- to reduce costs in the long-term by addressing young parents’ needs early.
In addition, the Lambeth FNP team is part of the FNP National Unit’s innovative ADAPT project (accelerated design and programme testing), working with Dartington Service Design Lab, which aims to rapidly adapt and test the FNP programme in England. Within this project there is testing of adapted clinical interventions targeting specific client needs, as well as further personalisation of the FNP programme to enable family nurses to shape support to meet the needs of individual clients. The project uses rapid cycle testing methodology to embed research-informed changes to the programme, monitor implementation and observe whether changes are making a difference. The Lambeth FNP team is focusing on clinical adaptations to the FNP programme which support the development of healthy relationships and reducing intimate partner violence.
The service is managed by Evelina London, within Guy’s & St Thomas’ NHS Foundation Trust. Accountability sits within the FNP board, which meets quarterly.
The commissioning director is part of the London Borough of Lambeth’s Children’s directorate.
Aligned to ‘Getting Child Protection Right’ – early identification of risks in the antenatal period by family nurses allow the issues to be highlighted to social care early in order for safeguarding plans to be carried out and put into action. In addition the Lambeth Health and Wellbeing Strategy, which includes early intervention and prevention, and Lambeth’s Borough Plan which includes targeted measures to reduce inequality for children and young people.
The FNP team in Lambeth works in partnership with many other services to ensure clients access relevant services and receive timely support. This includes working with partners such as:
- social care – adult and children’s including child protection teams, MASH, family support and Troubled Families teams
- early years and children’s centres
- maternity, hospital and community midwifery teams
- Guys & St Thomas’ and Kings Hospital staff
- adult mental health services and child and adolescent mental health services (CAMHS)
- primary care
- youth justice, courts, probation and youth offending teams
- DASH – Drugs Alcohol and Sexual Health
- St Michaels’ Fellowship – charity organisation for young people
- Unicorn Theatre – young mum’s theatre project.
Target service users
Clients are under 19 years of age, pregnant with their first child and living in Lambeth. The ADAPT programme has extended this to clients who are 20 – 24 years of age with one or more of the following risk factors; a history of significant safeguarding concerns or history of being a looked after child, substance misuse, a history of serious mental health issues or a learning disability.
Aims for service users
In summary, FNP aims to:
- improve the pregnancy outcomes by improving antenatal health
- improve a child’s health and development through a focus on sensitive responsive care giving
- improve the confidence and self-esteem of new mothers, to raise their expectations within relationships and prevent a ‘victim’ mentality through domestic violence
- improve the client’s life-course aiming for a return to work or education.
- One WTE band 8a supervisor (job share three days/two days)
- Seven WTE band 7 family nurses (two funded by A Better Start, Big Lottery Fund)
- One 22 ½ hours band 5 quality support officer which supports office administration, data entry and its quality
- Supervision of the family nurses is provided by the two supervisors.
- The supervisors are line managed by the provider lead, Evelina Community Health Trust and Head of Children’s Services.
- Additional safeguarding support is provided from the safeguarding lead nurse bi-monthly for the whole team.
- Psychological consultancy is provided by provided by the PAIRS (Parent and Infant Relationship Service) team which is managed through SLAM (South London and Maudsley mental health services). PAIRS is a service provided in LEAP (Lambeth Early Action Partnership).
The team is based at Gracefield Gardens in Streatham. The nurses all work out of children’s centres, in the community and within Homestart centres.
Family nurses work with clients in their homes wherever possible. Visits may take place outside of the home, for example at a local children’s centre or within the community.
The team cover the borough of Lambeth, and follow clients who have been moved out of the borough where able and if appropriate.
There is an open notification process from all services but the majority come from hospital or community midwifery teams at Guy’s & St Thomas’ Hospital and King’s College Hospital, ensuring the team can see clients in early pregnancy. Referrals also come from social care and young people’s hostels, and clients can self-refer.
Threshold and capacity
Within FNP each family nurse holds a caseload of 25 clients. Within Lambeth it has been slightly reduced to 24 clients per WTE family nurse with each FNP supervisor having a reduced caseload, meaning approximately 180 service users per year are served.
Work with service users
Family nurses visit clients in their homes on a one-to-one basis, working from early pregnancy until the child is two years old. The visit pattern is weekly for the first four weeks in pregnancy, then fortnightly. This becomes weekly again when their baby is born, for six weeks, then to fortnightly until the child is 21 months, where it becomes monthly in preparation for graduation. Through the ADAPT project we are also testing personalisation of the FNP programme. This means we can dial up or dial down the number of visits with clients depending on assessment of progress and individual needs. The ADAPT project is also testing the possibility of graduating some clients early (before their child is two) if the client no longer needs this intensive service and can be supported by universal services.
We also have a monthly FNP group at a local children’s centre where we invite FNP clients and their infants. This is a good opportunity for clients to meet each other, interact and support their child’s development through play and activities in a safe and friendly environment.
FNP is a voluntary programme. If clients choose not to participate then they are transferred to the local health visiting team for universal services. Depending on their individual circumstances or identified vulnerabilities they may be allocated to the Early Intervention Health Visiting Team. The same will happen once they graduate from the programme when the child reaches two years old. During the programme clients will be supported to engage with other relevant services such as children’s centres, so that they feel able to do this independently once the programme ends.
We are currently working with other local services to develop a vulnerability pathway to ensure that the move through and between services is robust, seamless and safe.
Performance indicators/target outcomes/achievements to date
Maternal and child outcomes in Lambeth:
- High breastfeeding rate:
- 95.6 per cent of FNP clients initiate breast feeding. (In England, the annual rate of breastfeeding initiation for the general population in 2016/17 was 74.6 per cent).
- 54.5 per cent of FNP clients’ breastfeeding at six weeks. (The aggregate breastfeeding rate in the general population for England for Quarter 3 2017/18, October to December 2017, was 43.7 per cent).
- Low rates of second pregnancy within this client group –14.8 per cent of clients had a second pregnancy by 24 months.
- Low attrition of clients
- Clients in education, employment or training 27.3 per cent at intake to the programme and 42.3 per cent at 24 months (over this last year).
- All infants graduating from the FNP programme had normal social and emotional development assessed by ages and stages questionnaires.
- A strong culture of flexibility within the team.
- Case studies show detail of individual achievements of impact on young people.
Early findings from the ADAPT project were published in an interim report, which showed that:
- greater personalisation in the FNP programme is possible in order to further shape the programme to the needs of individual clients
- defining and operationalising vulnerability in the clinical pathway has proved challenging – and is something the ADAPT project will dig deeper into
- meaningful co-production between practitioners, researchers and policy-makers requires persistence, creativity and good communication – and the FNP community will have some useful experience to share for the wider system from the ADAPT project
- an innovative method for rapid cycle adaptation and testing is being developed.
In addition the key documents used to support the ADAPT programme have also been published. This includes the documents used to guide the family nurses in Lambeth testing their clinical adaption of healthy relationships to reduce intimate partner violence.
FNP has been delivered in England since 2007. The Lambeth team was established in 2009.
We will continue to deliver high quality support to young mums and families in Lambeth through FNP. We will continue to test personalisation of the FNP programme through ADAPT, as well as the clinical changes to support the development of healthy relationships and a reduction of intimate partner violence. Through this work we hope to have a positive impact for young mums and families in Lambeth, as well as contributing to learning which can help to improve the FNP programme in England and have an impact for work with children and families more widely.
Family Nurse Partnership Head of Clinical Quality
Family Nurse Partnership Supervisor