Review of Nottingham City School Nursing

Transcription

1 Review of Nottingham City School Nursing Sarah Diggle Public Health, Nottingham City Council April

2 Contents Summary of key findings Background Review of School Nursing in Nottingham Methodology Findings Findings from the Data and Intelligence subgroup Findings from School Nurse Practice subgroup Key findings from Engagement Findings from Workforce subgroup Recommendations.37 2

3 Local Health Need - More than 1/3 of local children aged less than 16 years live in poverty. - There are significant health needs. - Children s health outcomes are worse than the England average on a range of indicators. Partnership working - Sharing of information with GPs and Early Years teachers is inconsistent. - Raised thresholds for transferring into CAMHS Tier 2 services are impacting School Nursing. Children and young people told us. - Support with mental and emotional health is as important as support with physical health. - Don t fully understand nurse s role / how to access. - Some lack confidence to go and knock on the nurse s door. - Youth friendly, accessible office needed. - Timetable on door (stating when nurse is available) would be useful. - Confidentiality very important. - Access during breaks/lunch recommended. - Page on school website /newsletter and use of text and social media recommended. - Introduce in assemblies clarify role. Model of delivery - Current model (most qualified nurses responsible for public health of secondary aged young people) is based on historical ways of working rather than on identified health needs. - The most qualified nurses are not necessarily supporting children with the greatest needs. School Nursing Review: Key Findings Summary Stakeholder s views and opinions - School nurses are greatly valued. - Lack of understanding about the role of the school nurse and how to access the service. - Schools, parents and young people would like to see more of the school nurses. Barriers to effective service delivery - Inadequate accommodation in some schools. - IT constraints within schools. - Significant and increasing safeguarding demands. Public health priorities Healthy weight is seen as the most important health priority for school nurses. Sexual health and relationships, mental and emotional health, alcohol, smoking and substance misuse were also perceived as important priorities (secondary). Self-harm is an emerging issue. Service delivery gaps - Inconsistent provision across City. - Uncoordinated provision of health promotion. - Lack of clear safeguarding pathway. - Inconsistent provision of sexual health services. - Potential inequity of provision for children/families attending special schools. - Lack of referrals to specialist services for parents/carers with health needs. - Lack of clarity regarding current and future funding and capacity required to support proposed increases in immunisation programmes. Workforce - Challenges with recruitment, training 3 and capacity.

4 Priority recommendations for development of school nursing 4

5 1.0 Background Commissioning the most appropriate children and young people's services has never been more important, with a focus on a preventable health service that offers equity, efficiency, effectiveness and excellence. Health is crucially linked with education. Good health and emotional wellbeing are associated with improved attendance and attainment at school, which in turn lead to improved employment opportunities. An evidence-based approach using prevention and early intervention reduces costs to society and to health, education and wider children s services in the long term. School nurses are specialist public health nurses, who deliver effective, evidence based public health interventions to school-aged children and young people. Together with their team, they lead and deliver the Healthy Child Programme, taking over from health visitors who provide services covering pregnancy and the first five years of life. As such, school nurses play a crucial role in ensuring that children, young people and families get good, joined-up support and access to available services at the earliest point, from a child s transition into school and continuing through their school-aged years. The government recognised the importance of school nursing in the public health strategy Healthy Lives, Healthy People and committed to developing a new vision for the role: Responding to local need, the school nursing service will work with other professionals to support schools in developing health reviews at school entry and key transitions, managing pupils wellbeing, medical and long-term condition needs and developing schools as health-promoting environments. The DH is developing a new vision for school nurses, reflecting their broad PH role in the school community. In March 2012, the Department of Health published Getting it right for children, young people and families: Maximising the contribution of the school nursing team: Vision and Call to Action. This guidance gives a new vision and model for the profession and is set within the context of the Healthy Child Programme 5-19, and is linked to the Public Health Outcomes Framework and Children and Young People s Health Outcomes documents published in August Key pathways which underpin the Vision and Call to Action include: - Supporting children to move from health visiting to school nursing services. - Delivering public health to young people in the youth justice system. - Supporting children with complex needs in school settings. - Safeguarding. - Emotional health and wellbeing. The nationally set service model for school nursing is described as follows school nursing is a Universal Service, which also intensifies its delivery offer for children and young people who have more complex and longer term needs (Universal Plus). For children and young people with multiple needs, school nurse teams are instrumental in coordinating services (Universal Partnership Plus). 5

6 Public Health Outcomes Framework Indicators in the Public Health Outcomes Framework (PHOF) came into effect in April 2013, and this includes 20 child specific outcomes. School nurses contribute to a number of these indicators (Table 1): Table 1: PHOF indicators that school nurses contribute towards Domain Indicator Domain 1: Wider Determinants School readiness Pupil absence Domain 2: Health Improvement Under 18 conception rate Excess weight in 4-5 and year olds Hospital admissions caused by unintentional and deliberate injuries in under 18s Emotional well-being of looked after children Smoking prevalence 15 years olds Self-harm Diet Domain 3: Health Protection Chlamydia diagnoses (15-24 years olds) Population vaccination coverage Domain 4: Healthcare public health and Tooth decay in children aged 5 years preventing premature mortality 6

7 2.0 Review of School Nursing in Nottingham The School Nursing service in Nottingham is delivered by Nottingham CityCare Partnership. The responsibility for commissioning school nursing transferred from Primary Care Trusts (PCTs) to Public Health in the Local Authority in April 2013 following the Health and Social Care Act. As part of the transition process, a full review of the service was undertaken between December 2013 and December The review had four key elements (Figure 1) with aims and objectives for each. A subgroup and separate action plans were developed for each of these areas (Table 2). Figure 1: Four elements of the Nottingham City School Nurse Review

8 Table 2: Key elements of the Nottingham School Nursing review and aims and objectives for each Review Element Aim Objectives Data and Intelligence - Develop school group health profiles to identify areas of need Engagement and Communication School Nurse Practice Workforce Scope Use local data and intelligence to inform the development of a needs-led service Ensure the views of all stakeholders including children and young people are considered in the development of the school health model for Nottingham and the model is effectively communicated to all Establish what the school health service should provide, to whom, when and where Identify the necessary skills and knowledge required to fulfil the new model and develop plans for workforce development as required - Determine local health priorities for the school nursing service - Identify gaps in current service provision - Establish the school health teams views on what changes in service delivery are needed in order to achieve the vision of Call to Action. - Engage with teachers, GPs and other stakeholders regarding their vision for school nursing - Engage with children, young people and to ascertain views on what the school nursing service should provide. - Communicate with all stakeholders the purpose and progress of the school nursing review throughout the process - Use insight gathered to define clear objectives and messaging for the communication plan - Raise the profile of school nursing by promoting an understanding of how school health teams can support achievement of outcomes - Benchmark current service provision - Identify evidence based interventions in order to deliver the requirements of the Healthy Child Programme - Develop a core offer for each of the four tiers - Identify the most appropriate structure for the school health team to meet the needs of the population - Develop strategies to retain new and existing staff - Develop a training and development programme The focus of the review was the school health service provided by Nottingham CityCare Partnership and not the Special School Nursing service provided by County Health Partnerships and the Youth Offender Nurses. These services are both commissioned by Nottingham City CCG. The CCG has been involved in this review process to ensure aligned delivery. 8

9 3.0 Methodology 1. A Steering Group was established and led by Public Health. Senior managers from CityCare Partnership School Nursing service were integral to this group. The Steering Group was instrumental in ensuring wider engagement and ownership of the review. The membership of the group was as follows: Nottingham City Council - Lynne McNiven, Consultant in Public Health - CHAIR - Chris Wallbanks, Programme Manager Early Intervention and Partnerships - Mark Andrews, Head of Family Community Teams North - Alistair Conquer, Head of Education Partnerships - Rachel Doherty, Partnership Manager - Sarah Diggle, Public Health Manager Nottingham CityCare Partnership - Phyllis Brackenbury, Assistant Director of Children, Young People, Families and Health Improvement - Jane Wilson, Children s Locality Manager - Stephen Upton, Project Manager, Nottingham CityCare Partnership - Linda Watson, Safeguarding Children Specialist Nurse - Gary Eves, Business and Performance Manager (Acting) NHS Nottingham City Clinical Commissioning Group - Alicia Rowley, Joint Commissioning Manager (Children and Families) 2. On-line questionnaires were designed and cascaded widely to all Schools, Chairs of Governing Bodies, GPs, wider stakeholders, School Nursing staff, parents/carers and young people. 3. Catch 22 and Social and Local were commissioned to undertake focus groups and interviews with key stakeholders (including a workshop for school nurses) including children and young people to supplement the findings of the questionnaires. 4. A range of task and finish groups were developed to map current school nursing practice, identify gaps, review the evidence and make recommendations for further development. This process was led by CityCare Partnerships School Health service. 5. National and local data has been analysed to develop a Nottingham City health profile for the school aged population. In addition, health profiles for each of the 15 groups of schools have been developed to support the school health service and commissioners target interventions appropriately. 9

10 4.0. Findings Summary of key findings Data and Intelligence Nottingham school aged population - There are 57,200 Nottingham citizens aged 5 19 years. - The current service is provided to 40,628 pupils aged 5-16 years through fifteen school groups (100 schools). - The number of children within each school group varies from 1545 to almost % of Nottingham City school pupils live within Nottingham City. - There are approximately 4,600 City citizens attending Nottinghamshire County schools. - There is a rise in the school aged population. - 45% of school children are from a black or minority ethnic group and English is not the first language for a quarter of young people. - The percentage of pupils from BME groups ranges from 13.4% (Farnborough group) to 76.7% (Nottingham Girls Group). - The dominant mosaic group for the majority of school groups is O (families in low-rise social housing with high levels of benefit) and I (lower income workers in urban terraces in often diverse areas). Gaps in provision - There is a lack of service provision for year olds, which will be an increasing issue with the change in the requirements to stay in education or training until age 18 years. - Providing a service to the extended age group increases the size of the eligible population by almost one third (32%) based on resident population. - There is a limited service provided to those attending independent schools. - It is likely that some home-educated children will not be receiving a service from School Health due to gaps in knowledge about which children are home-educated. The review has identified these children as particularly vulnerable. Health need - More than one third (19,000) of Nottingham s children and young people aged less than 16 years live in poverty. The average IDACI score for pupils in all of the school groups (with the exception of the Fernwood Group) is within the most deprived 40% nationally. - There are significant health needs amongst Nottingham s children and young people. - Health outcomes are generally worse than the England average on a range of indicators and there are wide variations across the City. 10

11 4.1 Findings from the Data and Intelligence subgroup School Population Currently, the School Nursing service provides to all pupils in Nottingham schools from reception to year 11 (5-16 years) with the exception of Oakfield Special School. According to the Nottingham School Census (March 2013), there are 40,628 pupils attending Nottingham Schools (including academies) (Table 3). 93.9% of pupils in Nottingham City schools live within Nottingham City. There are 57,200citizens aged 5 19 years. A limited school nursing service is provided to those aged years and it is largely limited to young people attending sixth forms within secondary schools. A service is not offered to those attending Further Education Colleges. Table 3: Number of pupils on roll by school phase in Nottingham (March 2013) Number of School Phase Pupil Roll schools Primary (including academies) 25, Secondary (including academies) 14, Special Pupil Referral Unit (PRU) 61 4 Total 40, Out of City pupils attending Nottingham schools During 2013, there were 2,478Nottingham City pupils (aged 5-16) who were resident outside of the City. This makes up approximately 6% of the population that the School Nursing service covers. There were also 4,584 City citizens attending Nottinghamshire County schools. Currently the school health service is provided to all those attending City schools irrespective of their place of residence Schools in Nottingham The current service is provided to fifteen groups 1 of schools as shown in table 4. This includes 77 primary, 14 secondary, four special schools and two PRUs. The number of children within each group varies from 1545 to almost 5000 (Table 4). The core service is not provided to pupils attending independent schools, although school nurse provision is available if requested. A table detailing all the schools in each group can be found in appendix 1. Additionally, it is estimated that there are 112 children from 76 families that are homeeducated. Nottingham City Council s Elective Home Education Co-ordinator provides information about the children being home educated on a monthly basis to school nursing so that the service is aware of these families and offers a service to them as required. However, it is acknowledged that some families will not accept the service offer and not all home educated children will be in the system. The review has identified these children as particularly vulnerable. 1 A group consists of one secondary school and the feeder primary schools 11

12 Table 4: School Nursing Groups of Schools and number on role Group name Number on role Nottingham Girls Group Trinity RC Group Bigwood Group Hadden Park Group Emmanuel Group Samworth Group Fernwood Group Farnborough Group Djanogly Group Bluecoat Group Top Valley Group Bulwell Group Nottingham Academy Group Ellis Guilford Group Nottingham Academy Ransom Road Group Woodlands Group Health needs Deprivation and the wider determinants of child health Deprivation strongly influences children s health outcomes throughout all aspects of their development. Successful early emotional, physical and social developments are essential to enhance a child s future ability to form positive relationships, improve their educational attainment and achieve good health. Deprivation also negatively impacts on a child s health through: their parent s age, level of education, whether they are unemployed and in good health, the environment they live in, housing quality, choice of nursery / schools, opportunities for social interaction and the quality of services accessed such as transport, leisure, libraries, shops, health and social care. The average IDACI 3 score for pupils attending the Fernwood group shows that they are the least deprived within the City and the Samworth Academy is the most deprived (Table 5). It is worth noting that the average IDACI score for pupils in all of the school groups (with the exception of the Fernwood Group) is within the most deprived 40% nationally. 2 Woodlands Group has not been included in further analysis including the health profiles due to insufficient data and the very small numbers in this group. The possibility of developing a profile for 2014/15 is being explored. 3 IDACI (Income Deprivation Affecting Children Index) is a measure of deprivation for children. 12

13 Table 5: School Groups ranked by average IDACI score of pupils and associated national IDACI quintile School Group Average IDACI score of pupils National IDACI Quintile Fernwood Group 0.18 Quintile 3 Trinity Group 0.33 Quintile 2 Farnborough Group 0.34 Quintile 2 BigwoodGroup 0.34 Quintile 2 Top Valley Group 0.34 Quintile 2 Bluecoat Group 0.35 Quintile 1 Emmanuel Group 0.37 Quintile 1 DjanogolyGroup 0.40 Quintile 1 Nottingham Girls Group 0.42 Quintile 1 Bulwell Group 0.42 Quintile 1 Ellis Guilford Group 0.43 Quintile 1 Nottingham Academy Ransom Road Group 0.46 Quintile 1 Nottingham Academy Group 0.47 Quintile 1 Hadden Park Group 0.47 Quintile 1 Samworth Group 0.51 Quintile 1 Nottingham s level of child poverty is worse than the England average with almost 19,000 (35.2%) children aged less than 16 years living in poverty. Health Needs The health and well-being of children in Nottingham is generally worse than the England average. Table 6 shows data on a range of indicators for Nottingham s young people, as well as the lowest and highest school percentage/rate where data is available. This shows the wide variation of need across individual schools. An assessment of health needs at individual school group level was also conducted which contributed to the development of school group health profiles. These can be found at: 13

14 Table 6: Nottingham City Health profile summary Health Indicator Number %/rate School lowest School highest Pupils living in poverty (under age 16) 18, % Not known Not known Pupils living in workless households 17,139 31% Not known Not known Family homelessness Not known Not known (per 1000 households) Children in care per 100,000 Not known Not known BME pupils 14, % 8.1% 93% Pupils where English is not first language 8, % 1.2% 87.1% School Action Pupils 6, % 1.3% 29.1% School Action Plus Pupils 2, % 0% 17% Statemented Pupils % 0% 4.6% Pupils with SEN 8, % 2.1% 39.6% 4 Pupils achieving 5+ A*-C including English 1, % 31% 71% and Maths GCSEs Pupils that are persistent absentees 2, % 0% 35.6% First time entrants to the Youth Justice 548 2,436 Not known Not known (per 100,000) System Pupils eligible for free school meals 12, % 7% 71.2% Pupils eligible and claiming free school 11,520 29% Not known Not known meals School meal uptake 6, % 10.9% 61.9% Child obesity in Reception (age 4-5 years) % Not Known Not known Child obesity in Year 6 (age years) % Not known Not known Under 18 conceptions per 1000 Not known Not known 4 Special schools excluded from this indicator to avoid skewing of data 14

15 Wolverh. Nottingham Sandwell Birmingham Manchester Leicester Bark & Dag. Nottingham Manchester Leicester Bark & Dag. Wolverh. Birmingham Sandwell Nottingham s data has been compared with that of its statistical neighbours and the England average for a range of indicators and a selection of these are shown below. More can be found at Rate per 100,000 of year olds receiving their first reprimand, warning or conviction (2010/11) Rate per 100,000 (age 0-17) for hospital admissions for self-harm (2011/12) 15

16 Ethnicity and Mosaic Group Overall, 44% of children aged 5 16 years in the City are from BME groups. This varies across the School Groups from 13.4% (Farnborough Group) to 76.7% (Nottingham Girls Group). The dominant mosaic group for the majority of school groups is O (families in low-rise social housing with high levels of benefit) and I (lower income workers in urban terraces in often diverse areas). The exceptions to this are the Farnborough Group, Emmanuel Group and the Nottingham Girls Group (Table 7). Table 7: Percentage of pupils from BME groups and dominant mosaic group for each group of schools School Group % pupils BME Dominant Mosaic Group Farnborough Group 13.4% K residents with sufficient income in right-to-buy social houses Bulwell Group 23.8% O Families in low-rise social housing with high levels of benefit Bigwood Group 25.0% O Families in low-rise social housing with high levels of benefit Top Valley Group 31.9% O Families in low-rise social housing with high levels of benefit Samworth Group 32.7% O Families in low-rise social housing with high levels of benefit Ellis Guilford Group 34.5% O Families in low-rise social housing with high levels of benefit Hadden Park Group 37.2% O Families in low-rise social housing with high levels of benefit Fernwood Group 47.3% D Successful professional living in suburban or semi-rural homes Emmanuel Group 49.2% N Young people renting flats in high density social housing Trinity RC Group 59.2% O Families in low-rise social housing with high levels of benefit Nottingham Academy Ransom Road Group 59.8% O Families in low-rise social housing with high levels of benefit Nottingham Academy Group 61.2% I Lower income workers in urban terraces in often diverse areas Bluecoat Group 73.0% I Lower income workers in urban terraces in often diverse areas Djanogly Group 74.3% I Lower income workers in urban terraces in often diverse areas Nottingham Girls Group 76.7% G Young, well-educated city dwellers 16

17 In summary, the development of the school health profiles has shown that there is substantial health needs amongst the City s children and young people and wide variation across the individual schools and school groups. It is imperative that the School Health service uses these health profiles to better understand their populations, so that they can deliver a needs-led service and contribute to a reduction in health inequalities. 17

18 4.2 Findings from School Nurse Practice subgroup Summary of key findings School Nurse Practice Capacity - Amongst 5-19 years olds resident in Nottingham, an estimated 42,900 (75%) of children and young people will be in the universal cohort, 8,580 (15%) will be in the universal Plus cohort and 5,720 (10%) will be in the Universal Partnership Plus cohort. - It is estimated that each registered nurse will have a caseload of more than 4500 children whom to provide the universal interventions in the Healthy Child Programme. - It is estimated that each specialist public health nurses will have a caseload of 1000 young people with urgent, long term or complex health needs and/or safeguarding concerns. - There are increasing numbers and complexity of high tier safeguarding demands and this takes up a large proportion of the time of the School Health Service. - The review indicates that the new government model may be a significant challenge with the current staffing levels. - Concern regarding capacity within the team to deliver the proposed new immunisation schedule. - Capacity could be improved by more effective use of skill mix within the team across the whole age range. Health need - The current service model is based on historical ways of working rather than on identified health needs. - The model does not ensure that the most qualified nurses are supporting children with the greatest needs. Service delivery gaps - The healthy child programme is largely being delivered to children with some gaps. - There is a lack of Standard Operating Procedures and pathways of care. - Lack of clear safeguarding pathway. - Uncoordinated and inconsistent provision of health promotion. - Inconsistent provision of clinic in a box and other sexual health services. - Immunisation status is not consistently reviewed in year olds. - Patchy provision of school leaver booster. - Potential lack of provision for children/families attending some special schools. - Lack of referrals to specialist services for parents/carers with health needs. - Lack of support for parents with learning disabilities. Partnership working - Sharing of information with GPs and Early Years teachers is inconsistent across the City. - Partnership organisations have raised thresholds for transferring into CAMHS Tier 2 services which is impacting the School Health service. - School nurses continue to hold cases which do not meet thresholds of other services. 18

19 It is recognised that the current service model is based on historical locality based decisions and not necessarily on identified needs. There is a baton passing delivery model in that all children are passed from Health Visiting to a band 5 member of the school nursing team once the child starts school at age 4/5 years. The band 5 nurse (along with their team) is responsible for the public health of these children until they are aged 10/11 years, irrespective of the needs of the child. The child is then passed on to a band 6 member of staff at year 7, until the child leaves school. The Health Visiting service has recently changed their service model, so that the cohort of children aged 0-5 years are split into the three tiers with the most qualified and experienced staff responsible for those infants with the greatest needs. Although children within the safeguarding caseload are part of the universal partnership plus tier, they have been separated out for clarity. The school nurse practice subgroup viewed this model as an appropriate way for School Nursing to develop to ensure a smooth transition from Health Visiting and also to provide a needs-led service in which the most qualified and experienced staff are supporting children and families with the most complex needs (figure 2). Figure 2: Nottingham City School Nursing -proposed needs-led model for delivery 19

20 4.2.1 Universal Service delivery Based on Health Visiting assessments, it is estimated that 42,900 (75%) of children and young people aged 5-19 years will be in the universal category. The Healthy Child Programme is delivered in all schools. This currently includes: Primary Reception handover from the Health Visiting Service for children commencing school. Parental health questionnaire during reception year. All Children (and preferably parent/carer) are seen during Reception Year for an Entrant Health Check. All children receive vision and hearing screening during reception year. Dental look and refer and issue of dental packs. Height and weight (National Child Measurement Programme) for all Reception and Year 6 children and routine feedback of results to parents/carers (excluding those attending special schools). Health promotion (Year 6 Menstruation & Puberty, Sun Safety, Hand Washing and Hygiene). Safeguarding Secondary Year 7 entrant health parent questionnaire to assess health need. Class/groups of Year 7s seen by School Nurse and Any worries questionnaire issued. If any concerns are raised by child, parent, teacher or carer then the child will be seen on a 1-1 basis to assess need and Year 7 targeted health assessment carried out. Introduction to the role of the School Nurse (for example assembly, year groups). Year 8 HPV talk to assembly and HPV immunisations (Girls). Health promotion (smoking, alcohol, substance misuse, sexual health and relationships, emotional Health) Drop-ins provided in all schools. Year 10 School leaver booster immunisations (Diphtheria/tetanus/polio) consents sent out to all in year group only those that are returned are vaccinated no proactive follow up is carried out. Safeguarding Challenges /Gaps in provision Sharing of information with GPs and Early Years teachers is inconsistent across the City. Limited universal provision for young people aged 16 and over. Inconsistent and uncoordinated provision of health promotion. Standard operating procedures need to be developed to ensure consistency and equality of service provision. Current method of identifying health need at year 7 may miss those young people with the greatest needs. Inconsistent provision of clinic in a box and other sexual health services. 20

21 Immunisation status is not consistently reviewed in year olds. Patchy provision of school leaver booster. Concern regarding capacity within the team to deliver the proposed new immunisation schedule. Adhoc requests for public health nurse support impacts greatly on the limited capacity within the team. An example of this is NHS England s recent request for support from the service to increase MMR vaccinations amongst years. Due to the transient nature of some families there is minimal opportunity to do any health intervention. Lack of referral of parents to specialist services (i.e. New Leaf) Universal Plus Service delivery It is estimated that approximately 8,580 (15%) of children and young people will be in this category. Current activity for those in this category includes: Reactive to individual identified health needs. Development and coordination of programmes of care where needs are identified. Continence management. Smoking cessation advice and support. Drug and alcohol misuse advice/support and referral. Sexual and emotional health advice and support Nutrition and healthy weight support and referral. Follow-up and assessment of children following hospital attendance i.e. A & E Safeguarding. Referral to specialist services as required. Challenges/ Gaps in provision High number of children receiving programmes of care. Lack of Standard Operating Procedures for school nurse interventions, for example, selfharm. Lack of clear pathway for emotional and mental well-being. School nurses continue to hold cases which do not meet thresholds of other services. School nurses do not always have the skills/training to support these cases which are held. Lack of referrals to specialist services for parents/carers with alcohol/drug use problems, smoking cessation and domestic violence. Lack of support for parents with learning disabilities to ensure equitable access to service information and support. Skill mix within the team not used effectively across the whole age range Universal Partnership Plus Service delivery It is estimated that 5,720 (10%) of children and young people will be in this category. Current activity includes: 21

22 Development and implementation of individual care plans for children with complex health needs. Multi agency partnership approach to support young people with a variety of complex and social needs: GPs Health Visitors, Education Sector, Social Care, Childrens and Adolescent Mental Health, Children and Adolescent Sexual Health, Speech and Language Therapy, Orthoptic, Youth Offending Team, Domestic Abuse Referrals Team, Multi-Agency Liaison Team, Police Probation Service, Children Centres, Local Authority, Children in Care Teams, Childrens Child Development Centres and Paediatrics. Where health needs are identified, School Health provides coordination and facilitation of all partners to ensure the health and well-being needs of a child or young person are met. Contribute to safeguarding children and young people who are experiencing, or are at risk of abuse (physical, neglect, emotional or sexual). o Band 5 and 6 nurses attend numerous safeguarding meetings: Initial Child Protection Conferences (ICPC ) Safeguarding review meetings GP red card meetings Common Assessment framework Meetings (CAF) Special Educational Needs meetings Children in Need meetings Children in Care meetings o Conduct chronology writing o School Nurses attend Safeguarding Supervision on a quarterly basis, either on a group or individual basis. o School Nurses attend mandatory safeguarding updates and improve their competence by attending specialist safeguarding training. Challenges/gaps in provision Inconsistent approach across the City. There are increasing numbers and complexity of high tier safeguarding demands and this is felt to take up a large proportion of the time of the School Health Service. Due to the risks at this level, this work is often prioritised leading to a reduction in provision at lower tiers. Partnership organisations have raised thresholds for transferring into Tier 2 services which is impacting the School Health service. Not all safeguarding meetings can be attended due to a lack of School Nursing capacity. Lack of workforce capacity makes the delivery of a robust safeguarding school nursing service challenging. Inconsistent expectations and requirements from different schools in relation to the role of School Nursing within safeguarding. Inconsistent expectations of School Nurse practitioners regarding safeguarding role. 22

23 Current provision is stretched. As illustrated in Table 8, each registered nurse will have a caseload of more than 3000 children whom to provide the range of interventions in the Healthy Child Programme and there are 12.2 WTE qualified public health nurses to support over 14,000 young people with urgent, long term or complex health needs and/or safeguarding concerns. Service delivery for these young people can be very intensive, for example the service had contact with 550 young people between April and September 2013 due to emotional and mental health concerns such as self-harm. There are nine WTE support staff (Nursery Nurses and Health Care Assistants). Table 8: Caseload size for the school health team based on 5-16 year and 5-19 year age groups. Level/ Cohort of children Number of practitioners (2012/13) Universal 9.5 WTE band 5 registered nurses Universal Plus 12.2 WTE band 6/7 and Universal specialist public health Partnership Plus nurses Approximate caseload size per nurse (based on 5-16 years population) Approximate caseload size per nurse (based on 5-19 years population) 3,200 children per nurse 4,500 children per nurse 800 children per nurse (of which approx. 340 in UPP) 1,150 children per nurse (of which approx. 460 in UPP) Table 9: Nottingham school health activities during 2012/13 academic year Autumn Term Spring Term Summer Term Academic Year Activity Group Total a) Health Assessment Related Activity b) Emotional Health c) Weight Management d) Sexual Health e) CAF Related Activity f) Safeguarding g) Dental h) Smoking/Substance Misuse i) Continence j) Complex Needs k) Multi Agency Work l) Other Contact m) Other Activity HPV Year NCMP Reception NCMP Year DPT Notes 1) The above figures include all activities recorded during the academic year ) The figures above include those which are directly with the child/young person or indirectly through a letter, telephone call, text 3) Multiple activities can be recorded against each contact with a child/young person therefore the figures do not represent the number of children/young peop 23

24 4.3 Key findings from Engagement Summary of key findings Engagement Views suggest that: Services A flexible service, based on the needs of the pupils within each school is required. A signposting role and the opportunity to provide a link to other health services are integral to the role. Health promotion is seen as an essential element of the service. There may be a gap in equitable service provision at special schools. Engagement with primary care is important. There may be some duplication of services. Clarity of role and pathways are needed. Importance of early intervention is recognised. Service needs to be more accessible and visible. There are not enough school nurses/not seen enough. Child protection - School nurses have little autonomy in assessing the level of involvement required. - If it felt that school nurse involvement in safeguarding activities should depend on: o Health concerns o Knowledge of the pupil o The involvement of other professionals o Whether the nurse has a role to play Health priorities Healthy weight is seen as the most important health priority for school nurses (both primary and secondary aged young people). Sexual health and relationships, mental and emotional health and alcohol, smoking and substance misuse were also perceived as important priorities for school nurses to be contributing to amongst secondary school aged young people. Self-harm is felt to be an emerging issue. Oral health and accident prevention were the least likely issues to be rated as most essential for secondary aged young people and first aid and administering medication were the least likely to be rated as essential for primary aged children. However, all health topics were viewed as important and interlinked. 24

25 Views and opinions - The school nurse is greatly valued. - There is a lack of understanding about the role of the school nurse and how to access the service. - The service is felt to be inconsistent across the City. - Schools, parents and young people would like to see more of the school nurses. - Children feel they can go to the school nurse if something is worrying them or they are feeling down. - Some young people feel uncomfortable/lack confidence to go and knock on the nurse s door. Barriers to effective service delivery - Almost 9 out of ten nurses reported that they encounter barriers in fulfilling their work. Key barriers are: o Inadequate accommodation in school o Difficulty finding parking o Lack of clarity about their role o Insufficient time/capacity to do everything o IT constraints This section provides a brief overview of the main findings from the engagement activities. Figure3: Nottingham School Nursing review engagement activities and numbers participating 25

26 1.3.1 Services There is some variation between the various stakeholders in terms of those services rated the most and least essential (table 11). It is worth noting however, that the majority of services were seen as important. For example, although provision of pregnancy testing was the service that the least number of young people rated as most essential within secondary schools; more than half of young people still agreed that pregnancy testing should be offered by school nurses. It is difficult to assess what a generic school nursing model should look like, as it needs to be flexible enough to meet the needs of the client group in each school/community (School nurse) As a special school we get no support for health and sex education. (Special School Head teacher) Key findings for this element were: The school nursing service needs to be flexible and based on the needs of the pupils within each school. Signposting role of the school nurse and the opportunity to provide the important link to other health services is integral to the role. Vision to be checked by orthoptics (School Nurse) Health promotion and activities to promote healthy lifestyles are seen as essential services. A coordinated approach to health promotion including sex education is required. Pupils attending Special schools may not be receiving an equitable service. Engagement with primary care is important. I believe sex and relationships education is very important but the methods used and the message taught is not uniform across every school (Parent/carer) There may be some duplication of services. Clarity of role and pathways are needed. Importance of early intervention is recognised. Service needs to be more accessible/visible. More staff would allow school nurses to do more than just the height and weight that they currently do (Parent/carer) There are not enough school nurses/not seen enough. school nurse needs to be a partner to the school, handling basic health check assessments as a health professional not to replace the teacher s role or to provide a basic first aid service (School Governor) 26

27 Table 11: Summary of services rated most and least essential by the various stakeholders Group Rated MOST essential Rated LEAST essential Primary Secondary Primary Secondary School Nurses Parents/ carers Other Stakeholders Children & Young People - Hearing and vision testing - Providing vaccinations - Activities to promote healthy lifestyles - Support for pupils with longterm health needs - Working with schools to identify and address health needs - Support for pupils with health conditions - Advice on how to access services - Appointments with individual young people - Facilitation of groups to support healthy behaviour change - Sexual health and relationship education - Sexual health provision - Drop-ins - First aid - Support for pupils with health conditions - First aid - Administering medication - Attending parent s evenings - Attending parent s evenings - Administering medication - First aid - Administering medication - Administering medication - Checking vision, hearing and weight - Attending parent s evenings - PSHE - PSHE - Administering medication - Provision of pregnancy testing Child Protection The key finding about the school nurse s role regarding safeguarding was that stakeholders and nurses believe that their level of involvement with child protection activities should be flexible and depend on: - Whether there are any health concerns - Whether the nurse knows the pupil - The involvement of other professionals - Whether the nurse has a role to play It is clear that school nurses currently find safeguarding activities to be very time consuming and that they are sometimes undertaking Primary role of the nurse is to know when to speak up (Secondary teacher) Social care should in some cases have all the information anyway for a family with a long history of safeguarding concern (School nurse about chronology writing) 27

28 unnecessary or duplicative tasks. However the nurses appear to have little autonomy in assessing the level of their involvement for each individual case. Schools and stakeholders are clear that nurses should not lead the process for the school. There is an acknowledgement by teaching staff that the safeguarding processes are unwieldy, but there was less clarity on how nurses might be used more effectively. As seen in table 12, the child protection service most likely to be rated as essential by both nurses and other stakeholders was the Initial Child Protection Conference (ICPC). Both rated chronology as one of the least essential activities, along with red card meetings (nurses) and home visits (other stakeholders). Table 12: Summary of child protection activities rated most and least essential by nurses and other stakeholders Group Rated MOST essential Rated LEAST essential School Nurses - Initial Child Protection Conference (ICPC) - Red card meetings - Chronology writing Other Stakeholders - Initial Child Protection Conference (ICPC) - Home visits - Chronology writing Health Priorities Healthy weight is clearly seen as a key priority for school nurses to contribute. Healthy weight was identified as the top priority within primary schools by school nurses, children and young people and other stakeholders. Young people also identified health weight as the most essential priority for secondary school children. Sexual health and relationships, mental and emotional health and alcohol, smoking and substance misuse were also perceived as the most important priorities for school nurses to be contributing to amongst secondary school aged young people. Sexual health and relationships was seen as the lowest priority for primary school aged children by school nurses, parents and stakeholders, along with alcohol, smoking and substance misuse. Oral health and accident prevention were perceived as the lowest priority for both primary and secondary school aged children. Family issues were seen as the lowest priority by children and young people. Although respondents ranked health priorities in order of importance, it was clear from comments that many found it very difficult to rank, as all were viewed as important with many of the issues being interlinked. Respondents emphasised the need for flexibility to ensure a needs-based service. It was clear that respondents recognise the importance of early intervention and the valuable access to the population that the school nurses have in addressing some of these health priorities. 28

29 Mental and emotional health was recognised as particularly important for secondary school aged young people. Nurses, stakeholders and parents identified self-harm as a particular emerging issue. Nurses also felt that parenting support was an important need. Table 13: Summary of health priorities rated most and least essential by the various stakeholders Group Rated TOP priority Rated BOTTOM priority Primary Secondary Primary Secondary School Nurses Parents/ carers Other Stakeholder s - Healthy weight (physical activity & nutrition) - Family and behavioural issues - Healthy weight (physical activity and nutrition) - Mental and emotional health - Sexual health and relationships - Alcohol, smoking and substance misuse - Sexual health and relationships - Sexual health and relationships - Alcohol, smoking and substance misuse - Sexual health and relationships - Alcohol, smoking and substance misuse - Sexual health and relationships - Oral health - Accident prevention - Oral health - Accident prevention Children & Young People - Healthy weight (physical activity and nutrition) - Healthy weight (physical activity and nutrition) - Bullying - Family issues - Family issues - Oral health Views and Opinions The key finding from this section is that there is strong agreement about the value of the school nurse and the opportunity for the service to positively impact on the health of children. However there was equally very strong agreement amongst all stakeholders including children and young people about the lack of understanding about the role and responsibilities of the school nurse and how to access the service. 29

30 Figure4: Summary of statements that had the greatest and least level of agreement by the various stakeholders LEAST Agreement GREATEST Agreement - Service delivery is consistent across the City. - Morale within the team is good. School Nurses - School nurses have a positive impact on children s health - My relationship with school is good - School nurses are often seen around school - I am clear about the school nurse s role Parents/carers - School nurses have a positive impact on children s health - Parents/carers know how to contact the school nurse - Children know how to contact the school nurse - Children know who their school nurse is Other Stakeholders - School nurses have a positive impact on children s health Other key themes that were derived from analysis are: School nurses are not visible within school and some children are not aware that they have one. Schools, parents and young people would like to see more of the school nurses and this was echoed by school nurses who also felt they should have increased contact with children and families. Knowledge of the school and continuity of service is important to schools. I thought this was a hypothetical survey do we have school nurses these days? (School Governor) Our nurse is great but I wish she could be here more often (Head teacher) 30

31 Service delivery is felt to be inconsistent across the City. Children and young people feel they can go to the school nurse if something is worrying them or they are feeling down. Children think there are not enough school nurses/they don t see them enough. Children and young people think that being friendly/confidential/good listener are important attributes for the school nurse. Young people think that the nurse gives good advice and helps with making decisions. I think we could do a lot more to improve links between school nursing and primary health care teams (GP/Practice staff) She should be in more often and persuade people that they can talk to her about confidential stuff. (Young person) My school nurse is great,she gives great advise and is very friendly,she has recently booked me an appointment with the doctors that iwouldnt of dontmyself,idont know what i would do without her shes the best xxx (Young person) Some young people feel uncomfortable/lack confidence to go and knock on the nurse s door. The school nurse is someone young people can trust. Gender of the school nurse can be important Attendance at assemblies would help to introduce the nurse and their role. They should do regular check ups (Young person) Current delivery and barriers to effective delivery School nurse perspective Findings from the engagement with the school nursing team suggest that the most satisfying part of their role is working with children and families and making a difference to their health/lives. However, it is evident that many of the nurses currently feel frustrated due to the numerous difficulties and barriers in delivering their role. Almost 9 out of tensurvey respondents reported that they encounter barriers in fulfilling their work. Key barriers reported are: Inadequate accommodation in school Difficulty finding parking at school/health centres Lack of clarity about their role (particularly amongst those working in secondary schools).. having an adequate room in schools to offer patients confidential and high quality service. Sometimes being seen in corridors or small kitchens. Therefore often cramped or interrupted by staff. When schools do not value your presence and do not work with you. E.g. will not provide contact telephone numbers for parents or will not provide you with a room even when you ring in advance IT facilities are not always available, despite having a laptop, often freezes during writing documentation. Lack of S1 in schools is a huge problem and really stops me doing my job effectively 31