Michael Little addressed the Family Nurse Partnership Annual Study Day in Manchester on the 22nd of November. Here is what he said.
It is a great privilege to be invited to speak at the FNP National Study Day. I suppose I would count myself as FNP’s number one fan, except that many others will be vying for that position. There are lots of things I want to say, but I only have 20 minutes. So I will just draw out some highlights.
Achievements
We are having the toughest of times for over a century. You work with people who feel the economic downturn most. But your achievements are significant. Over 6,000 families receive FNP. That is a market penetration of 10 per cent. In the US I reckon that after about 30 years they have reached 15 per cent. So you are really motoring. More importantly, the replication of the model has been strong. We know this from the Birkbeck research. For the most part -there is always room for improvement- FNP has been implemented as it should be implemented. That is crucial for delivery of better outcomes for mother and child. By now, so skilled are you at this work, you probably do not think this is such a big deal. But I can remember the host of other government initiatives that broke all the rules:
- For example, those that had no evidence base
- Those that lumped together several evidence-based programmes willy-nilly
- Or where volume was put ahead of fidelity.
With one or two notable exceptions, nearly all of these efforts resulted in zero impact on child or family outcomes, and most are long gone and forgotten.
Even now we are not supposed to talk about these huge errors of government. Millions of pounds were wasted by taking perfectly good products, dismantling them and then re-assembling them badly. It was FNP’s good fortune that it fell into the hands of sensible people who put what was right ahead of political expediency.
Money
We can argue about the figures but roughly speaking the state spends about £5,000 per child per annum. It doesn’t sound like a lot, but nationwide it adds up to about £55 billion. And at FNP you are asking that we blow £6,000 on a single intervention. It is a big ask. It is a credit to those of you seeking commissioning that you have made the case. Your job must have been difficult, and it has been getting more difficult, and it will be more difficult still as the recession continues to bite. If we were informed gamblers, we would see FNP as a safe bet. Yes its a reasonably big outlay, but the returns are significant. The econometric model that Dartington has been developing for the UK calculates that each £6,000 chip is going to bring in about £16,000 of returns.
Why? Because FNP mums are more likely to go back to work. Because child protection concerns are decreased by over a half. Because in the long run the children are more likely to do well at school and less likely to bother youth justice services. Because mother and child are healthier and make fewer demands on the NHS. Since we are cautious souls, we run what we call a ‘Monte Carlo Simulation’ in our models. This is like saying, 'I know I might get lucky on the casino tables one or two nights in a row, but what would happen if I played for 1,000 nights, including those times when everything was going wrong?'. And it turns out that 99 times out of 100 FNP will always pay off.
These kinds of calculations have led to different ways of thinking about commissioning. We have helped local authorities to make investments that not only improve child outcomes but also generate an economic return. Social finance organisations are bringing private finance into the equation. Payment by Results turns the outcomes into pounds and pence.
FNP is a slam-dunk, home-run, and every other type of cliché you want to apply to an investment that is bound to pay-off. I would put my money into FNP tomorrow if the mechanism existed. The commissioners in the room will be exploiting these opportunities, and getting social care, schools, and youth justice to invest as much as the health service has invested, knowing that they are going to be primary beneficiaries.
Culture
What helps FNP is your sober approach to evidence. There is a culture of not over-claiming. Don’t lose this.
Recently I went with a venture philanthropist to a large UK city to reflect on potential investment opportunities. Each programme we saw claimed, in the absence of any credible evidence, to be 70 per cent successful'. Whenever I hear the words ‘my programme is 70 per cent successful I zone out since I have never encountered anything that was 70 per cent successful. When we got to FNP, we were told that although FNP had been subjected to three experimental trials, all showing significant effects on child outcomes, the UK evaluation was still underway. When the venture philanthropist asked about Group-FNP, he was told this was still very experimental, under development and some way from being ready for prime-time.
It was a breath of fresh air. And for a venture philanthropist today, and I suspect for public sector investors in the future, it injected some predictability into a series of conversations that have been marked by guesswork. The need for honesty, predictability, and transparency is going to feature strongly in future commissioning conversations and I urge you to hold on to your values.
Scale
My current passion in this work is helping to take some proven models to scale. In the UK we have many, many interventions, few of them proven, some of them harmful, a handful like FNP backed by strong evidence, and none of them scaled.
In the same UK city I visited with the venture philanthropist, there were 100 FNP places to meet potential demand of 350. Scaling up in that city meant finding another £1.5 million. Another big ask. But the advantages of scale are huge. Not only are more children and parents served, but a public health effect is produced. Parents who don’t come anywhere near FNP begin to behave like FNP parents. A contagion is produced.
So, to my mind, I am asking, instead of funding 10 things, nine of which have at best a dubious evidence base, why not scale two or three things in which we have most confidence.
So whereas Kate and Ann rightly have their eye on the prize of 60,000 places England wide, I am hoping you have your eye on scale in your locality. That might be just 50 places, or three to five hundred in a big city. If you can do it, you will be the first people in the world, to take an evidence-based programme to scale, and to bring all the benefits for families that this promises.
The challenge of scale is huge. As a general rule of thumb, most things proven to work have not been scaled, and most things taken to scale have not been proven. I recently helped to convene a major conference on the subject at the Gates Foundation in Seattle and here are some of the things I have learned.
First, scaled products are personal products. So while evidence-based programmes like FNP demand fidelity, scaled programmes will require adaptability to suit the user. We can do both, but it takes a little extra thought to work out how.
Second, people don’t want to know how something works, they just want to know what it will do for them. The iPhone is a good illustrator of these two points. We don’t want to know how it works, just that it will make calls, link to the internet, play music etc. We make an iPhone our own. We personalise it. People don’t need to know how FNP works, just what it will do for them. And your secret weapon is the relationship between nurse and parent and child. This is the personal bit.
For those of you responsible for managing FNP, similar personal connections are needed with systems folk commissioning FNP. They need to feel they are bringing something specific to meet local needs, something that preserves the fidelity of the core but allows adaptability around the edges. Something that allows an added dimension designed with Manchester, or Newcastle, or Preston in mind. Context is king in the world of scale.
Third, stories matter. Numbers, trials, effect sizes etc matter. They really matter. But once we know the evidence, we can engage hearts and minds by telling the stories to which human beings, parents, relatives, social workers, general practitioners, relate. This, in my experience, has been a strength of FNP in the UK, and you can use it to greater effect in the scaling process.
Fourth, most successful scale-up links a product with a process. The combine harvester, that transformed the US from a largely agricultural to a largely industrial nation, was linked to the invention of hire purchase. The Ford Model-T was linked to mass production. Toyota, the world's most successful motor car company, 60 years ago a sewing machine producer, is linked to ‘Just in Time’ technology. Microsoft, the world’s greatest scale-up triumph, is a product of two big bets paying off at the same time. Bill Gates bet on Windows software. His colleagues bet on packaging that software so that it could be licensed and sold with any computer, meaning they did not have to be computer manufacturers. FNP is the world beating product. What process is going to help us scale it?
Messages for the Workshops
I will close with some messages for the workshops that follow. I cannot comment on the organisational aspects of the work since that is well outside my expertise, but there are some messages from research that might be relevant for the other groups.
Quality improvement is going to be a recurring theme in the next decade. It is intrinsically tied to the question of scale. Public expenditure will get progressively tighter. We can cut or we can get better at what we do well. Scaling evidence-based programmes like FNP is on the 'getting better at what we do well' side of the equation.
I have urged commissioning strategies that seek local scale-up of FNP. The first person in this room to meet the needs of every high risk, young prospective mother will be the first person in the world to scale an evidence-based programme. I am betting that the returns will be much greater than the benefits that accrue to the mothers who are supported, that there will be a contagious effect. If you are on this journey to local scale, give me a call because I want to be on the journey with you. It's the next big frontier.
Your achievements over the last four years have been remarkable, and this makes sharing the learning difficult. We don’t embrace success in this country. But your sober approach to implementation, respectful of evidence but putting the child and family first, should be hugely instructive to the children’s services workforce. To me this is more than sharing ‘top tips’, it's about making the best practice routine practice. I really hope there may be some investment in this task.
On data collection, you have, unlike most children’s services operations, good data. You probably have too much. The challenge is reduce it to the information that the nurse and the mother really need to know in order to achieve the best outcome for the child. This will be a defining challenge in children’s services in the next decade since we collect too much data and do too little with it. Its draining our resources that could be better invested in kids.
Safeguarding. There is a simple message here. FNP is, to date, the best-proven model for preventing child abuse. By far. It is fantastic that the Health Service has invested so heavily in FNP but I am hoping that social care will become the major purchaser since your product is the best on the market for reducing avoidable harm to children. Yes, you have to get your safeguarding right, and you will talk about this in your groups, but don’t lose sight about the intrinsic safeguarding capabilities of FNP.
And let me finish on relationships and encouraging positive, sensitive parenting. Conflict in families in ubiquitous. Living with other people is not easy. About five per cent of families resolve this conflict using violence. Not minor violence, severe violence. Most of these families are unknown to children’s services, and the damage to children in terms of clinical disorders is considerable. Most of us resolve conflict badly. We resort to psychological aggression, we use minor physical violence, for example slapping our kids. This is the norm but it is not healthy. It elevates the risk of conduct disorder for children three-fold. This is not a problem for other people’s children, it is a problem for most of us in this room.
So for me, another scale challenge is how do we take the components that have made a programme like FNP so successful, changing the behaviour of the most at risk new parent, and translate them into a form that we can reach every new parent. How do we spread the idea that ordinary conflict in the home can be resolved with a little more awareness, more mindfulness and little less angst, and getting our own way and hitting.
This public health approach to child protection, changing what all of us do at home, has the potential to radically improve the well-being of UK children.
Conclusion
I hope those remarks were of some value to you. FNP is arguably the best evidence-based programme available. The implementation in the UK has been exemplary. It's a success story. So let's break the habit of a lifetime and celebrate. But more importantly, lets use the success as a platform for the next challenge. For me that is scale. Not so much 60,000 places, which seems unattainable at the moment. But achieving scale in a number of significant places, say here in Manchester, or Birmingham, Nottingham maybe. The place doesn’t matter as much as achieving this more modest goal and estimating the value added by virtue of the contagion and other public health effects produced. I very much hope some of you will make that important journey.
