Version 2 – draft School nurse scrutiny paper – 09/02/12

Hertfordshire County Council

School Nurse Scrutiny – February 2012

Report Author: Kay Gilmour Transformation Manager Children’s Services

Hertfordshire Community NHS Trust

The purpose of the School Nurse Scrutiny is: To understand the current service delivery and how the service has adapted to reflect the needs of children aged 5 – 19; to understand the barriers to achieving consistent delivery of the full service specification across the county; to understand how key relationships affect service delivery; to identify the effective processes and data which need to be in place to support service delivery; to understand how the service links with other services and how it provides support and continuity for Looked After Children in Hertfordshire.

Introduction

This paper has been written to demonstrate the current School Health Service provision and challenges in Hertfordshire for the purposes of scrutiny, outlining the service aims, service delivery model, service priorities, key performance indicators, key service strengths and the current challenges. The School Nursing workforce information is contained in Appendix 1.

Service Aims

The aim of the School Health Service is to:

  • Achieve positive health, emotional and psychological well being for all children and young people through an evidence based programme of screening, immunisations, health reviews, health promotion, health interventions and personal, social and health education.
  • Work with other members of the Healthy Child Programme(DH 2009) team across localities, primary care, community and education ensuring the best use of resources for example Paediatricians, Speech Therapists, Mental Health Workers, General Practitioners, Community Nursing Teams, teachers, Attendance Improvement Officers, Social Care, Children’s Centres, the Children Looked After Team.
  • Deliver a service that focuses on prevention and early intervention supporting the drive to reduce the cycle of health inequalities within families and reduce problems and service costs in the short and long term.
  • Deliver the Healthy Child Programme for children and young people from 5-19 years (a commissioning developmental goal is from school entry which may be before the age of 5 years).

Service Delivery Model

The School Health Service is delivered across the six Hertfordshire localities and is aligned to ten HCC districts denoted in brackets. The localities are Dacorum (Dacorum); Watford (Watford & 3Rivers) East & South (Broxbourne & East Herts), St Albans & Harpenden (St Albans & Hertsmere), Welwyn & Hatfield (Welwyn & Hatfield) North Hertfordshire (North Herts) & Stevenage (Stevenage).

The School Health Service in East & North Hertfordshire is integrated into 0-19 team service provision with Health Visitors, Community Staff Nurses and Nursery Nurses, to optimise the use of skill mix.

The service delivers a universal service to all children within state schools in Hertfordshire which moves to targeted interventions for those children and families with identified additional needs.

Work Prioritisation

Within Hertfordshire work is prioritised according to service capacity, in order to manage this situation work prioritisation has been in place for the past three years. School Health work is prioritised according to a traffic light system.

Red – priority work

Safeguarding, Vulnerable Children, Looked after Children, Immunisation Programme, School Entry Health Assessments & screening, support for children with complex health needs, Domestic Abuse, targeted A&E work.

Amber - core

This is additional work to the priority work highlighted above and includes the provision of open access drop-in sessions, continence services, A & E follow up, support for children with complex needs at health reviews.

Green – non urgent

New parents evening

Secondary transfer

Personal Social and Health Education (PSHE)

Not in education, employment or training (NEET)

The delivery of the service specification varies across Hertfordshire with the majority of areas delivering only priority work areas. Particular areas of low service delivery are working with children with poor school attendance or at risk of exclusion and the NEET population which is of particular concern since these children and young people are vulnerable. School drop in provision, new parent contact and parenting support are regularly requested by schools but provision due to capacity is limited.

Service Strengths

The school nurse teams consistently deliver their key performance indicators (Appendix 1)

  • School nurses make a unique contribution, addressing the health issues relevant to children and young people in school, their clinical knowledge and the confidentiality of their service are particularly valued by young people.
  • Feedback from the school nurses in Hertfordshire showed that many school nurses care passionately about their work and the potential value of school nursing.
  • In Hertfordshire there are 1041 Looked After Children. School Nurses work closely with the CLA team to coordinate and provide statutory annual health reviews for those children aged 5 and over.
  • The School Health staff report spending significant amounts of time leading the CAF process and as a key partner in the Team around the Family (TAF).
  • Staff members work alongside Children’s Services (Social Care) in providing the health expertise to the Targeted Advice Service for incoming referrals which do not meet the thresholds for social care.
  • The School Nursing services work in partnership to share relevant health information with the Family Nurse Partnership for young women aged 19 years and below who are expecting their first baby.
  • The School Health Service has remained extremely flexible and responsive to service requirement changes and HCHS staff has very successfully delivered mass immunisation programmes.
  • The School Health Service has responded effectively and in a highly organised way to the challenges of Chlamydia screening targets.

Challenges

One of the key challenges to service delivery is the workforce capacity and this is detailed in Appendix 2.

  • In recent years new national agendas such as the national child measurement programme and HPV programme have had a major impact on the capacity of the school nursing service to deliver a full service to children and young people across the county.
  • Safeguarding and child protection casework, including the assessment of the health of Looked After Children has risen considerably.
  • Requests from schools for support and assessment of children with behavioural difficulties or emotional and mental health concerns has also shown a significant rise particularly when these children fail to meet CAMHS criteria.
  • The immunisation and screening programmes are very labour intensive and within the last two years HPV catch up and the implementation of Audiology screening has significantly increased the workload on the teams.
  • The role of the school nurse is to provide professional support and care planning for children with complex needs in mainstream and special schools. Teams report that they can only achieve this in mainstream schools and often that much of this is left to the parents.
  • A current source of frustration for the school nursing teams stems from the number of training places available to staff to undertake the SCPHN Programme (2 this year). This is due to the current focus and investment in Health Visiting where the current resources are being deployed.
  • Particular challenges within some parts of the county has been the 0-19 model where school nurse numbers have resulted in pockets of isolation which has been addressed by grouping school nurses together as a team. Equally the estates provision in some areas has not enabled school nurses to integrate into the 0-19 CUS teams.
  • There are challenges in Clinical Commissioning Groups fully understanding the breadth of the role of the school nurse and there is work to do to promote and market the value and contribution our staff make to young people.
  • With the development of Academy schools the delivery of the HCP for school children may become more fragmented, particularly if schools decide to opt for private providers or a reduced service. Where this has happened in the past the controls put in place have not always assured a quality service and school children may be at risk of a reduced and non evidence based provision. This can result in completely unregulated practice within schools and unqualified providers of care.
  • Academy status may also offer opportunities for the service where an enhanced service over and above the core offer could be purchased. The feedback from the service indicates that schools frequently request services outside the scope of the specification
  • Capacity alone is not always the barrier to the delivery of the HCP within schools. There is no statutory requirement for schools to work with the school nursing services. One example of this is the refusal of a minority of schools to agree to the carrying out of the NCMP. Similarly a minority of schools will decline drop in services or will make requests for PSHE delivery which is neither evidence based nor needs led. Immunisation sessions can be disruptive to the school day and diplomatic negotiation is often required to facilitate routine care delivery. Unfortunately the health provider cannot always influence decisions as there is no statutory requirement for schools to support the delivery of the HCP.

Key Relationships

School Nurses key relationships are with schools and a range of education staff including designated teachers for Looked After Children, HCHS CLA team, Children’s Centres, Children’s Services (Social Care), CAMHS, GP’s, Paediatricians and Youth Connexions.

Processes and data

There are four identified areas which would transform the way in which the School Health staff could operate more effectively, safely and efficiently. This could be achieved through strong partnership working.

  1. There is a constant need to ensure that the School Health Team has accurate and up to date information. School lists are required centrally on a termly basis. There is an urgent need for HCT to receive pupil information in the first instance to ensure that caseloads are correct and that vulnerable children are not unallocated to a Health Professional.
  2. Where children relocate it is equally as important that this information is shared.
  3. The provision of a suitable environment and adequate space to deliver immunisation and screening programmes.
  4. Where 3G connectivity is difficult for the School Health, county wide agreement to access the school Wifi network or wired network to allow the staff to continue to successfully access the electronic records whilst delivering care.

Appendix 1.

Service delivery key performance indicators

Currently there are three universal key performance indicators (KPI) which the service is measured upon contractually:-

KPI / Target:% activity coverage of eligible cohort / 2010/11 achievements
Reception Screening (heights & weights) / 93.6% / 12626 - 99.02%
National Childhood Measurement Programme Year 6 / 89.6% / 11831 - 99.02%
Year 8 HPV immunisation programme / 1st / 2nd vaccination 87%
3rd vaccination 85% / West Herts dose 1: 3374 (87%)
E & N Herts dose 1: 2978 (87%)
West Herts dose 2: 3348 (87%)
E & N Herts dose 2: 2951 (87%)
West Herts dose 3: 3258 (85%)
E & N Herts dose 3: 2916 (85%)

Appendix 2

Locality Profiles

In Health Visiting a nationally recognised weighted model exists (Cowley 2009). This model enables the service providers to establish the Health Visiting requirement within a given locality based on the Index of Multiple Deprivation. There is no comparable model in existence for School Health Teams currently.

Choosing Health (DH 2004) outlined the Government’s aims of increasing the number of school nurses to one WTE year round qualified school nurse working with each cluster of primary schools and related secondary school.

South Locality

Deprivation score –16.22 (average)

Hertfordshire rank – 2nd

Children with child protection plans aged 5 and over - 12

Numbers of primary schools- 31

Numbers of secondary schools - 7

Caseload population -15095

Qualified School Nurse WTE ratio per secondary schools1: 1.82

Qualified School Nurse WTE ratio per primary schools1:8.09

Skill mixed nurses WTE (including Qualified School Nurses) ratio per locality schools1:5.3

East Locality

Deprivation score –7.41 (average)

Hertfordshire rank – 10th

Children with child protection plans aged 5 and over - 11

Numbers of primary schools - 73

Numbers of secondary schools - 13

Caseload population- 27123

Qualified School Nurse WTE ratio per secondary schools1:2.37

Qualified School Nurse WTE ratio per primary schools1: 13.32

Skill mixed nurses WTE (including Qualified School Nurses) ratio per locality schools1: 8.48

North Locality

Deprivation score –10.69 (average)

Hertfordshire rank – 8th

Children with child protection plans aged 5 and over - 29

Numbers of primary schools - 49

Numbers of secondary schools - 6

Caseload population - 16121

Qualified School Nurse WTE ratio per secondary schools1: 2.1

Qualified School Nurse WTE ratio per primary schools1: 9.9

Skill mixed nurses WTE (including Qualified School Nurses) ratio per locality schools1: 6.76

Welwyn and Hatfield

Deprivation score –14.18 (average)

Hertfordshire rank – 4th

Children with child protection plans aged 5 and over - 39

Numbers of primary schools - 41

Numbers of secondary schools - 6

Caseload population - 14129

Qualified School Nurse WTE ratio per secondary schools1: 2.16

Qualified School Nurse WTE ratio per primary schools1:14.8

Skill mixed nurses WTE (including Qualified School Nurses) ratio per locality schools 1:10

Stevenage

Deprivation score –16.42 (average)

Hertfordshire rank – 1st

Children with child protection plans aged 5 and over - 31

Numbers of primary schools - 33

Numbers of secondary schools - 11

Caseload population - 15661

Qualified School Nurse WTE ratio per secondary schools1: 2.3

Qualified School Nurse WTE ratio per primary schools1: 7.08

Skill mixed nurses WTE (including Qualified School Nurses) ratio per locality schools 1:6.8

Watford & Three Rivers

Deprivation score –Watford 15.81 (average); Three Rivers 10.74

Hertfordshire rank – Watford 3rd; ThreeRivers 6th

Children with child protection plans aged 5 and overWatford – 40; Three Rivers - 15

Numbers of primary schools - 62

Numbers of secondary schools - 8

Caseload population - 20000

Qualified School Nurse WTE ratio per secondary schools1:2.78

Qualified School Nurse WTE ratio per primary schools1:21.6

Skill mixed nurses WTE (including Qualified School Nurses) ratio per locality schools 1:9.3

St Albans & Harpenden

Deprivation score –8.88 (average)

Hertfordshire rank – 9th

Children with child protection plans aged 5 and over - 40

Numbers of primary schools - 47

Numbers of secondary schools - 13

Caseload population - 28886

Qualified School Nurse WTE ratio per secondary schools1: 5.24

Qualified School Nurse WTE ratio per primary schools1: 18.95

Skill mixed nurses WTE (including Qualified School Nurses) ratio per locality schools 1: 11.32

Hertsmere

Deprivation score –12.86 (average)

Hertfordshire rank – 5th

Children with child protection plans aged 5 and over - 22

Numbers of primary schools - 34

Numbers of secondary schools - 6

Caseload population - 16832

Qualified School Nurse WTE ratio per secondary schools1: 2.41

Qualified School Nurse WTE ratio per primary schools1: 13.7

Skill mixed nurses WTE (including Qualified School Nurses) ratio per locality schools 1: 7.54

Dacorum

Deprivation score –10.73 (average)

Hertfordshire rank – 7th

Children with child protection plans aged 5 and over - 26

Numbers of primary schools - 60

Numbers of secondary schools - 8

Caseload population - 20000

Qualified School Nurse WTE ratio per secondary schools1: 4

Qualified School Nurse WTE ratio per primary schools1:30

Skill mixed nurses WTE (including Qualified School Nurses) ratio per locality schools 1:11.5

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