Those of us with an interest in early intervention know the history of the Family Nurse Partnership (FNP) well. The programme was developed in the US, based on the idea that maternal sensitivity laid the foundation for early learning and that sensitive parenting behaviours could be taught to vulnerable mothers through intensive home visiting.

US evidence from three robust trials confirmed that many of the programme’s intended benefits could be achieved. These included improved birth outcomes and reductions in maternal smoking at the time of the child’s birth, reduced rates of abuse and neglect throughout the early years, improved cognitive skills in primary school and reduced antisocial behaviour and reported arrests during the teenage years. While the intervention was not cheap (costing approximately £2,000 per child), economic analyses showed that these benefits were financially meaningful and could potentially provide a return of 6 to 1 (Aos et al., 2004).

FNP was introduced to the UK by the Cabinet Office in 2007 as part of a new government focus on tackling intergenerational disadvantage, and carried forward by the Department of Health. Led by a dedicated National Implementation Unit, it represented one of the biggest central investments in early intervention made in recent years, and in many ways became a test case for early intervention.

There were high hopes for the intervention and the first two years of trial data were eagerly anticipated. Then, in 2015, the UK programme’s first ‘Building Blocks’ trial showed that the intervention did not replicate any of the benefits observed in its previous studies, including those which the UK researchers had identified as ‘primary’, involving rates of maternal smoking, child birth weight, accidental child injuries and subsequent maternal pregnancies (Robling et al., 2016).

This provoked significant debate as to whether these primary outcomes were the right ones. Particularly given that high-quality universal health visiting services were already available in the UK, it was argued, the programme was unlikely to add value in terms of support for the perinatal period (Barlow et al., 2016). It was also clear that the findings were not wholly negative, as the study observed consistent improvements in child language skills, although these benefits were considered secondary. This led the Building Blocks researchers to conclude that continuing the programme in the UK was unjustified, particularly in light of its considerable expense (Robling et al., 2016). In recent years there has been significant disinvestment in the programme.

Our view at the time was that it was too early to tell. As set out by Jason Strelitz in a blog for EIF, it was not clear if the 2015 results were telling us an inconvenient truth or if this was just a bump in a road on which we had some distance left to travel.

And so the findings from the Building Blocks trial published last week represent an important moment, both for FNP and wider early intervention.

1. The Building Blocks trial shows that FNP provides children with a consistent educational advantage throughout the early years

The Building Blocks study observed a statistically significant and consistent educational advantage for FNP children over their non-FNP peers that was first present already at age 1 and then maintained five years after programme completion. What is particularly noteworthy about the findings from the most recent study is that FNP children were more likely to be assessed by their teachers as achieving a good level of development through the Early Years Foundation Stage Profile (EYFSP) at age 4 and achieving their expected standard of reading through the key stage 1 assessment at age 6.

These are important outcomes from the standpoint of children’s development. As we observed in our 2017 report, Language as a child wellbeing indicator, cognitive capabilities during the early years are consistently associated with children’s success at school and entry into the workforce. While EYFSP and key stage 1 scores are not perfect predictors of academic success, they are reliable predicators, and so they are considered to be indicative of improved life chances (Atkinson et al., 2021; Treadaway, 2019).

Further work to weigh the costs and benefits of FNP, as a major national investment would be useful. Nonetheless, these are important findings when compared to the benefits achieved by other interventions offered to vulnerable families. Improved cognitive outcomes are rare for these types of programmes: our Foundations for Life report identified only five (out of a total of 20 assessed) with evidence of improving cognitive outcomes. FNP was the only one of these five with evidence of an improved cognitive outcome lasting five years or longer.

2. We need to do more to find out how best to prevent child maltreatment

However, the Building Blocks evaluation also found that FNP was not successful in reducing rates of child maltreatment. This suggests that the support provided by the current FNP model is not sufficient for reducing rates of child maltreatment in this highly vulnerable group of families (over 20% of participants who were in the programme or in the control group were on the child protection register or identified as a child-in-need, which is high in comparison to the rate of 2.5% in the general child population). The national FNP unit is continuing to test and adapt the programme in an attempt to improve outcomes in this area, but we also need a wider effort to find out what works for children at risk of experiencing maltreatment. The UK evidence base on how best to support children and families where there is a risk of child abuse and neglect remains too limited.

3. FNP exemplifies the importance of long-term evaluation

These findings are the result of a five-year follow-up study. Long-term follow-ups are the exception and not the rule for most early years’ interventions (and more widely) in the UK, but are important in obtaining an accurate picture of impact. When the first wave of the Building Blocks trial was published, our view was that it was too soon to form overall judgments as to the efficacy of FNP in the UK. While not all interventions lacking short-term benefits will eventually show positive results, in the case of FNP the follow-up was necessary to confirm its added value within the UK.

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So, in conclusion, an ambitious long-term follow-up, comparing FNP children to their randomly selected peers, has found that FNP does improve children’s life chances and can add value in the UK. Through long-term evaluation we now have important new UK evidence that FNP has the potential to improve the life chances of highly vulnerable children and improve their cognitive development. This is not only good news for FNP recipients, but also for all of us who champion early intervention. Nevertheless, while there is something to celebrate here, there is also an urgent and crucial reminder that more must be done to find out what works to prevent child maltreatment.

References

Aos, S., Lieb, R., Mayfield, J., Miller, M., & Pennucci, A. (2004). Benefits and costs of prevention and early intervention programs for youth. Washington State Institute for Public Policy.

Atkinson, A., Hill, L., Pettinger, K., Wright, J., Hart, A., Dickerson, J., & Mon-Williams, M. (2021). Can holistic school readiness evaluations predict academic achievement and special educational needs status? Evidence from the Early Years Foundation Stage Profile.

Barlow, J., Barnes, J., Sylva, K., Fonagy, P., & Fearon, P. (2016). Questioning the outcome of the Building Blocks trial. The Lancet, 387(10028), 1615–1616.

Robling, M., Bekkers, M. J., Bell, K., Butler, C. C., Cannings-John, R., Channon, S., ... & Torgerson, D. (2016). Effectiveness of a nurse-led intensive home-visitation programme for first-time teenage mothers (Building Blocks): a pragmatic randomised controlled trial. The Lancet, 387(10014), 146–155.

Treadaway, M. (2019). How attainment gaps emerge from Foundation Stage to Key Stage 4, part one.