This is certainly what is happening in 10 areas of England, where early intervention is taking on a whole new meaning. The 10 areas are piloting the £7m Family Nurse Partnership Programme, providing first-time teenage mothers with intensive, regular home visits from family nurses from pre-birth until their child is two.
The idea that you can make a difference to a child’s future before they are even born might sound far-fetched, but the US programme’s credibility is backed by almost 30 years of evidence-based research by its founder David Olds, professor of paediatrics at the University of Colorado. The Nurse-Family Partnership – as it is known in the US – is now in use in more than 280 US counties, as well as in the Netherlands and Germany, and discussions are being held with other countries.
Olds developed a home-visiting programme after working at an inner city day care centre in Baltimore in the US in the 1970s. He realised that the care four-year-olds received was too little too late and that the only way to effect change was by working with parents and children much earlier in life. The programme that he developed targeted first-time, low income women who received visits from a registered nurse from pregnancy until the child reached two.
The three major goals were to improve health in pregnancy and pregnancy outcomes child health and development and future school readiness and achievement, parents’ economic self-sufficiency.
Clinical trials have shown the programme’s success in, for example, cutting child abuse and neglect by 48%, reducing arrests by 59%, reducing the use of benefits, and improving educational achievement.
The starting point for bringing the programme to England stemmed from government opinion that, while there had been improvements for families and children through initiatives such as Sure Start and free child care, more focused work was needed to support and improve outcomes for some.
With mounting evidence that poor attachment, stress during pregnancy, harsh parenting and low levels of stimulation are strongly associated with negative outcomes later in life, it made sense to look to a programme that targeted even younger children.
First sight of the government’s policy to set up the 10 pilot areas came in last year’s social exclusion action plan. As well as a geographic spread, government criteria ensured the areas had a range of population groups, a history of good partnership working, and a sufficient workforce. Each area has a target to work with 100 families, with each family nurse involved carrying a caseload of 25 first-time mothers under the age of 20. All family nurses are trained midwives or health visitors.
Kate Billingham, project director of health-led parenting and first years of life and responsible for evaluating the pilots during their two-year run, explains: “The traditional way of doing things is to look at someone’s need and then say to them ‘because of these problems you need this programme’. But here we say ‘you are eligible for this programme and it will help you be the mum you want to be and have a healthy baby’. It’s very positive.”
Keeping it as a universal service is particularly important for this age group because there is no stigma attached, Billingham says. “If you have eligibility criteria that asks a lot of questions, such as were you in care, do you take drugs, when did you leave school, they won’t engage with the programme.”
Her views are born out by the 90% uptake from the teenagers who have been offered the programme – a much higher figure than Billingham expected.
Referrals come from midwives, and the mothers-to-be must be no more than 28 weeks into their pregnancy to be eligible for the programme. US research shows that, after this, the “magic moment” when women want the most for themselves and their baby has been missed.
“This programme seems to be the missing bit of the puzzle,” she says. “There has been a lot of work around Sure Start and early years but not pregnancy and the first two years of life.”
However, the programme is seen by some to be in competition with the health visiting service in terms of qualified personnel. A recent survey by the Community Practitioners’ and Health Visitors’ Association of 1,000 health visitors revealed that a decline in numbers has resulted in more than half making fewer visits to families because of larger caseloads, and community staff nurses and nursery nurses taking on a health-visiting role in some areas.
Billingham – a health visitor by profession – suggests the problem is more about a lack of investment in the service than a shortage of health visitors. She says the pilots can strengthen health visiting by offering programmes for different levels of need within a universal service. But the Community Practitioners’ and Health Visitors’ Association warns that any such service will only work if it is targeted accurately.
The first three babies out of an expected 1,000 across the 10 pilots in England have been born. It will be at least another decade before we can be sure, but their future already looks more promising. “If we could achieve half the results they have had in the US it would be great,” Billingham says.
Alison Kalwa, family nurse, Somerset
‘Support for the right people at the right time’
Health visitor Alison Kalwa was attracted to the role of family nurse in the Somerset pilot because “it provides intensive support to the right people at the right time”.
Somerset is piloting the programme in four areas, with two full-time and three part-time family nurses based in children’s centres. So far they have 40 out of the target 100 families on board.
As well as offering the programme to all those under 20, Somerset has extended it to first-time mothers aged 20-24 who aren’t in education, employment or training, or where there is another factor that would make them vulnerable, such as a mental health problem, a lack of support, or poverty.
Visits cover a wealth of issues under several topics: personal health, including mental health, nutrition and exercise environmental health, looking at whether the home is suitable for a baby life course development, such as family planning, education and livelihood the maternal role, which looks at their own experience of being mothered and the care of a newborn baby and family and friends, looking at their personal support network. In each, the family nurse encourages them to share their hopes, fears and expectations, and set goals where appropriate.
The depth of discussion and number of topics means there is a big difference between the work of a family nurse and a health visitor, Kalwa says. “A health visitor covers about 10 topics like breastfeeding and what happens in hospital in one visit lasting up to 45 minutes. A family nurse does 14 visits during pregnancy lasting up to one and a half hours. And visits have a set pattern so that families learn about structure and reliability, and feel safe.
“All the discussions are getting the mum to think about the baby in a positive way and promote the attachment to the baby before it’s born,” says Kalwa. “They are so receptive to changing their behaviour and taking on information.”
THE 10 SITES (back)
South East Essex
➔ For more information on the US programme
➔ Reaching Out: An Action Plan on Social Exclusion
➔ Preventing social exclusion: the health-led parenting project
Contact the author
This article appeared in the 26 July issue under the headline “The earlier the better”