Investment for tomorrow? OK but we need the proof – today

One of the factors that makes a proven program sustainable is a general perception on the front line that it fits and works.

In that respect, politicians are not alone in their appetite for a quick fix; local practitioner confidence and morale can depend on good early results.

And in the present climate that pressure creates a curious dilemma: the strain on service budgets is increasing just as prevention scientists are becoming surer footed in campaigning for long-term strategies for securing better outcomes for a generation of vulnerable young people still in their infancy.

The pinch of opposing concerns is being felt by the Nurse Family Partnership, in the midst of extensive UK field trials in its cross-Atlantic Family Nurse Partnership (FNP) mode.

An evaluation report on second-year progress in the first ten UK pilot sites is just published.

“Doing fine” is the slant on the results announced by the UK Department for Children Families and Schools, last week.

"Effective delivery is having a positive impact on some of the most vulnerable young families in society … there are signs that the program is having a positive effect on reducing smoking during pregnancy and increasing rates of breastfeeding", says their press release.

Professor Jacqueline Barnes and her University of London FNP Implementation Research Team acknowledge these and other promising indications.

Their interviews with families, professionals, commissioners and managers also suggested healthy involvement of fathers and much appreciation of what family nurses were achieving.

But they say more than DCFS does about the paradoxical demand on the pilot schemes to secure long-term commitment to the program by demonstrating short-term results.

“Tensions are emerging from commissioners and other service providers in the areas when decisions are being made about whether to sustain the program after the pilot period, which will end in approximately 18 months when all the first cohort of clients’ children reach 24 months of age,” they write.

“There are unreasonable expectations that local teams should be able to produce evidence that the program has made a difference, to justify its perceived high cost, despite the fact that this is primarily a preventive intervention. Long terms gains over one or two decades are what makes it cost effective and gains may not be within the health domain but in other areas such as education, employment or criminal justice.

“Some of the staff, possibly responding to these pressures, have felt insecure in these new roles and have moved back to more familiar work, which has proved problematic for the remaining team members.”

Barnes and her colleagues also comment on the inertia in existing systems at the outset and reflect on how the role of family nurses might eventually be assimilated.

“These ten sites had the unenviable job of being the first to deliver an innovative but complex intervention program, under a spotlight of national interest and within a tight time-frame. In the first year of the evaluation it was evident that there was a struggle to recruit sufficient clients while at the same time becoming familiar with a vast array of materials and developing a new way of working.”

And elsewhere they say:
“For some there is an expectation that, given the different populations and service contexts, the outcomes identified in the US trials will not be forthcoming in England. The integration of FNP into Children’s Centres also has some way to go. The level of understanding of many Children’s Centre managers about FNP and how it can be integrated with other services is limited.”

The optimistic calculation behind the DCFS headline is that FNP has delivered a 20 per cent relative reduction in smoking during pregnancy and a breastfeeding initiation rate of 63 per cent compared to a national rate of 53 per cent for this group.

The original ten pilot sites reported on are Barnsley, County Durham and Darlington, Derby, Manchester, Slough, Somerset, South East Essex, Southwark, Tower Hamlets and Walsall. That number has since been increased to 40 and is expected to reach 50 by January 2010 and 70 by April 2011, with a view to rolling it out across England over the next decade.

To read the Implementation Research Team report see: The Nurse-Family Partnership Programme: Implementation in England Second year in 10 pilot sites: the infancy period [1]