Be flexible: lessons from FNP ADAPT


Finlay Green | Researcher | @FinlayGreen_ 

Finlay Green, researcher at the Dartington Service Design Lab, reflects on lessons learned from Rapid-Cycle Testing with FNP ADAPT, and the key to success.

In monsoon conditions in the last week of May, academics, policymakers, and practitioners came together to explore ‘Rapid-Cycle Adaptation and Testing (RCAT) at scale in complex service delivery settings’. The prism through which we viewed this was the first stage of the Family Nurse Partnership (FNP) ADAPT programme.  We’ve been working with the FNP National Unit to adapt and test their home-visiting programme for new mothers – this seminar was sharing what we’re learning so far.

The speakers and panellists, made up of those from FNP, the Lab and beyond, left the attendees with one over-riding message: whether you’re a practitioner delivering frontline services, a researcher evaluating those services or a public health commissioner deciding how to spend your money – be flexible.


Be flexible in clinical practice

Leaders and practitioners from all parts of the programme, including FNP nurses, spoke about the change in working culture that rapid cycle testing requires.

A cross-cutting theme from all was that rapid-cycle testing requires a change in working culture for all of those involved, from researchers and policy-makers through to family nurses themselves. But what does this change mean in practice for nurses?


Rapid-cycle testing requires a change in working culture for all of those involved.

 For Julia, a nurse from Dudley, adding flexibility to her clinical practice was a major challenge. FNP has historically had a strong focus on programme fidelity, with nurses encouraged to deliver the same number of visits of the same length, and covering the same content, to all of the young mothers with whom they work.

One of the changes that ADAPT has since introduced is ‘personalisation’ – which requires a relaxation of this focus on fidelity. Nurses are now encouraged to work more with mothers who need more support, and less with those who don’t, while also adapting the content of visits to the specific needs of each mother. Julia and her colleagues are using this new agency to full effect, pulling content from across FNP to deliver what they see as the best possible programme for every mother.

The team are now happier in, and bringing more energy to their jobs. For mothers, Julia reported that the extra control they’ve been given over what they get out of FNP has improved their level of engagement.


What has a change in working culture meant in practice for nurses?


Be flexible with research

The experience of the FNP ADAPT project so far suggests that flexible, iterative methods like rapid-cycle testing help organisations to learn more about improving their services, and to learn it faster. But presenters and panellists, including Dartington Service Design Lab’s Louise Morpeth, had valuable insights to share on the challenges that this brings.

Being iterative, failing fast and often, improving as you go – these aspects are hard work. They involve going backwards, dropping carefully crafted ideas and seeing failure and learning from failure as an indication of a healthy project – easy to say, hard to do. In a public health context, resource is scarce, the stakes are high and the stress on the system is intense. The pressure for constant, unwavering progress is strong. In this climate, it can be tempting to hedge your bets and develop and test a big, glorious suite of adaptations, in the hope that doing more stuff will lead to more stuff being successful.

One of the key messages from Ailsa Swarbick, Director of the FNP National Unit was: resist this temptation. It’s better to do fewer things well than lots of things badly. When the second phase of ADAPT starts in October, it will involve a sharper, narrower focus on fewer adaptations, while the local FNP sites involved will also be asked to take on adaptations one at a time, rather than all at once. Doing iteration well requires focus, prioritisation and building incrementally on strong foundations.


Be flexible with evidence

For the commissioners in the room, the lack of (traditionally understood) ‘rigour’ offered by rapid cycle testing was difficult to grapple with. They wanted the certainty that randomised control trials gave them that what they were delivering was the best available option, according to the best-available evidence. The response from the panellists, including Tim Hobbs (Director of the Lab), Tom Rahilly (Director of UK Programmes, Save the Children) and Leon Feinstein (Director of Evidence, Children’s Commissioner’s Office), was universal: if we want to use evidence well, we have to be more flexible than that.

Doing iteration well requires focus, prioritisation and building incrementally on strong foundations.

RCTs only provide a partial picture – and as Louise Morpeth said, it’s a picture in the rear-view mirror. In order to make informed commissioning decisions, knowing what worked on average somewhere else with a different group of people is of limited use. Instead, you need to know what will work for who and why, in your local context – it’s these questions that FNP ADAPT is seeking answers to.

Find out more about our work with FNP ADAPT on our project page.