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Analysis: Targeting nurse care

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A new nurse-led model of care for vulnerable mothers is being piloted across England. Louise Tweddell reports on its progress.

Importing care models is always a controversial move, as initial reaction to the Family Nurse Partnership Programme (FPN) confirmed.

News that ten pilot sites for a US programme to target vulnerable families were to be set up in England in 2006, followed by a further 20 last November, proved contentious in a climate of falling health visitor numbers and rising caseloads.

At the time, stakeholders said the money would be better invested in health visiting as a whole, rather than a programme targeting a relatively small section of society.

However, an independent review of the programme suggests that it could prove popular with the profession in the long term.

The Nurse-Family Partnership, as the model is known in the US, was the brainchild of David Olds, professor of paediatrics, psychiatry and preventive medicine at Colorado University, over 30 years ago.

It provides planned weekly and fortnightly visits for first-time mothers from low socioeconomic backgrounds. Women between the ages of 20 and 24 can join the programme from the start of the second trimester of pegnancy until their child is
24 months old.

Focusing on the social, emotional and economic factors of each mother’s life, the programme targets parenting skills, with the aim of promoting both the child’s health and well-being and the mother’s quality of life.

Randomised control trials in the US have shown the FNP is linked to a reduced likelihood of child abuse, a reduction in antisocial behaviour in adolescent children who have been through the programme, and fewer pregnancies per mother within the scheme.

The clinical impact of the programme in England is still unclear but an independent evaluation of the first pilot sites – now over a year old – in areas including Tower Hamlets and Manchester has recently been published (NT News, 15 July, p2).

Overall, the independent study concluded that the FNP has the potential to be effective in England. Researches from Birkbeck College, part of the University of London, and the Institute of Children Families and Social Issues, interviewed those who had taken part in the pilots including mothers, fathers, whole families and all 57 family nurses (FNs) and their supervisors.

The programme was seen by families as a way to gain extra support and information, researchers found. The FNs were highly regarded, being seen as non-judgemental and considered as a ‘friend to turn to’.

‘The findings are promising – the report says the FNP can be delivered effectively in this country, that it is reaching and having an impact on some of the most vulnerable families in society,’ said Kate Billingham, the Department of Health’s project director for health-led parenting and first years of life.

But there have been stumbling blocks. Targets were not always met on family recruitment, nurse visits and data collection.

The programme exceeded its family recruitment target of 75%, with 87% of those offered a place on the programme accepting.

However, it fell short of its target to have recruited 60% of pregnant women by 16 weeks gestation or earlier – achieving only 51%.

In addition, it exceeded the US model’s record for an attrition rate of just 10%. Although one site had a rate of less than 10%, on average it was between 11% and 24% in England.

Researchers also found that only 52% of planned visits were being carried out as opposed to the target of 80%, and that FNs were spending an average of 73 minutes on each visit – 13 minutes longer than target.

Recruitment difficulties, FN training schedules, and a concentration of new clients needing more frequent visits were cited as contributory factors by the report.

Ms Billingham said: ‘It’s early days and we’re testing a new programme that is very different from existing services. We think many of these results are due to the rapid set up of the programme and getting the right systems in place.

‘Nurses were training and recruiting clients in a short period, which meant that they needed the most frequent visits at the same time,’ she added.

So what are the views among grassroot providers? According to the report, FNs were extremely satisfied with the programme. It states that many described the role as the ‘best job’ they had ever had.

Ruth Rothman, a family nurse supervisor with South East Essex PCT, said: ‘I wanted to do this because, with the best will in the world, I was not being able to give the support I wanted to my clients while I was a health visitor. I felt in this role I would be able to, and I really can.

‘You learn to look for clients’ strengths, not their weaknesses – see the positive things they have managed to achieve and build on these.

‘I do not go in there and say you have not done this but say haven’t you done well to achieve that. It is about helping them make decisions to make the changes themselves,’ she added.

However, FNs gave a clear message on caseloads and working hours.

The average FN was found to be working an average of six hours and 45 minutes more than their contracted hours per week. They also felt under pressure to fit caseloads around their own training commitments.

One nurse told researchers: ‘I don’t want to work a 50-hour week’, while another said: ‘I started to think about looking
for a new job.’

Ms Rothman was reluctant to comment on whether she had experienced problems with hours or caseloads. ‘We all came to this with our eyes open and knew it was going to be a challenging process,’ she said.

Ms Billingham was unable to confirm any government commitment to funding for extra nurses to reduce these pressures but she indicated that she expected the situation to stabilise as the pilots became more established.

‘This is something we take seriously. The nurses are doing a fantastic and highly demanding job but we don’t want them to be overloaded,’ she said.

‘Again, we think this is partly a feature of the speed and intensity of set up,’ she added.

There is currently no long-term plan for the FNP beyond 2010 but the pilot sites will continue to be assessed and monitored.

This will include a randomised control trial to determine their clinical benefits – a process which will be key in any decision to continue the programme.

However, those on the frontline are confident about the FNP’s future. ‘We know this is making a difference and it really has been possible to transfer the programme from the US,’ said Ms Rothman.

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