On the money? Family Nurse Partnership

A major new research study published in the Lancet questions the benefit of Family Nurse Partnership (FNP), saying that it shows little benefit over care as usual (CAU) and is not cost effective. The study concludes by stating: 'Adding FNP to the usually provided health and social care provided no additional short-term benefit to our primary outcomes. Programme continuation is not justified on the basis of available evidence, but could be reconsidered should supportive longer-term evidence emerge.'

According to Dr Michael Robling, School of Medicine, who led the research, 'On the basis of the limited benefit to families seen in the trial, continued provision of the Family Nurse Partnership programme cannot currently be justified in the UK'.

Family Nurse Partnership is a voluntary, preventive programme for vulnerable young first-time mothers. It offers intensive and structured home visiting by specially trained nurses, from early pregnancy until age two. FNP has three aims: to improve pregnancy outcomes; improve child health and development; and improve parents' economic self-sufficiency.

Developed in the USA in the 1970s by David Olds, after extensive trials it was more widely provided in the 1990s. It was adapted for use in the UK because it showed better outcomes for mothers around prenatal health, and fewer and less closely spaced pregnancies. There also appeared to be longer-term benefits: children did better at school, were less likely to be involved in youth crime, and had fewer accidents and mental health problems.

It was introduced in the UK in 2007. In England, the programme, backed by the Department of Health, has worked with 26,239 teenagers in 130 different local authorities. In Scotland the programme is currently provided in eight NHS Board areas - Lothian, Tayside, Fife, Greater Glasgow and Clyde, Ayrshire and Arran, Forth Valley, Highland and Lanarkshire with NHS Borders and Grampian due to come on stream.

The research aimed to assess the effectiveness of giving the programme to teenage first-time mothers on infant and maternal outcomes to 24 months after birth. The researchers did a pragmatic, non-blinded, randomised controlled, parallel-group trial in community midwifery settings in 18 partnerships between local authorities and primary and secondary care organisations in England. Between June 16 2009, and July 28 2010, 3,251 women were screened. After enrolment, 823 women were randomly assigned to receive FNP and 822 to usual care. The research showed that that adding the FNP programme to usual care provided no additional short-term benefit for the selected primary outcomes (smoking in pregnancy, birthweight, emergency hospital attendance and admission for the child, and subsequent pregnancy). The lack of benefits evidenced by this research means that the degree to which the programme can be assumed to be beneficial when comparing it to previous trials in very different health settings is limited.

Previous evaluations have generally been based on FNP work in the USA; have been small scale; and often evaluated by the programme designers themselves. The model is not directly transferable, in that in the US, there is no universal health visiting service, and therefore, any comparison between the intervention and CAU is taking a very different starting point to the UK.

The research raises major questions about the future of FNP in the UK. Against the outcomes which the research measured, and against which the programme was commissioned, the study states unequivocally: 'In conclusion, [the study] found there was little advantage to adding FNP to existing health service provision in England, and was not cost effective in terms of maternal outcomes'. However, the report also says that any benefits to child health and development would be more likely to arise after the age of two, so that longer-term research is required to assess that. The researchers plan to continue their research looking at FNP's efficacy in preventing maltreatment, and would like to extend this to accommodate emotional, behavioural and developmental outcomes for the child and life course outcomes for the mother.

Proponents of the programme claim that measured against 'softer' outcomes such as attachment and emotional and developmental outcomes, FNP is effective. While the research suggests that the intervention's expense is not justified by its results, others say that it can have a long-term impact on children's lives. The question remains whether the same outcomes could be achieved and the money better spent with an enhanced health visiting programme such as the new framework currently proposed by the Scottish Government.  Phil Wilson writes about this here.

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