Features

Is school nursing DNR?

08 February 2018

School nursing services across the UK are being changed, cut, expanded and integrated into other teams. With no apparent UK-wide consensus on what their role should be, do school nurses have a future in the modern NHS? Journalist Sarah Campbell investigates.

School nursing is at best a mixed picture at the moment. On one hand, the school nursing workforce in England – including nurse consultants and school nurses without a school nurse qualification – has shrunk from a high of 3026 in January 2010 to 2396 in August 2017 (NHS Workforce Statistics, 2017) – a decrease of 21%. On the other, the number of nurses with the specialist community public health nursing (SCPHN) school nurse qualification on the NMC register – which covers all of the UK – increased by 17% from 3032 to 3556 between 2012 and 2017 (NMC, 2017). Note that these NMC figures don’t mean all these people are working as school nurses, just that they hold the qualification.

Certainly, if you read the newspapers, a shortage of school nurses is putting children’s lives at risk (Connett, 2017). But speak to school nurses around the UK, and you’ll discover functioning, efficient services – as well as areas where school nursing services no longer exist.

 

What’s going on?

There are many reasons for this uneven picture: local authorities, mainly in England, make decisions about school nursing services based on local needs, with resulting differences in local school nursing business models. School nurses can be highly involved in local commissioning – or not, depending on local commissioning models, budgets and levels of skill and confidence among school nurse leaders themselves. So it’s largely in England where the biggest discrepancies in models occur; the devolved nations tend to take a national approach – but more of that later.

Besides all this, the role of the school nurse is changing significantly, for the most part expanding. The first school nurses appeared around the turn of the 20th century, and their role was cemented in 1907 when a law was passed that obliged schools to provide all children with medical inspections. Nowadays, health assessments are still a part of the school nurse’s job – but only a part. On top of this, they carry out home visits to families in difficulty, run immunisation clinics, are heavily involved in safeguarding, lead public health programmes such as healthy eating and smoking cessation, and signpost children and parents to other services and information. 

Paula Fletcher, a school nurse in Liverpool, relishes this changing role but doesn’t feel the balance is right yet. ‘We do a lot of safeguarding in our area so we go to a lot of child protection meetings,’ she says. ‘However, a lot of the time we’re asked to attend as a healthcare professional to make the meeting quorate when in fact we might not know the child or be best placed to help make decisions about him or her.’

For Paula, these meetings take up so much of her time she doesn’t feel she has the chance to do the early intervention work she believes children really need. ‘Ideally, I’d love to be based in school and be seen more by the children,’ she says. ‘And while I have a diploma in CAMHS, I think that all school nurses should be upskilled in mental health issues.’

 

Cautious optimism

Paula’s health trust is undertaking a consultation on changes to the service. ‘It’s exciting: I think we’ll have more control over what the service will look like in the future,’ she says.

Paula’s cautious optimism is shared with other school nurses around the UK – but not necessarily around the rest of England. At the Aneurin Bevan University Health Board (ABUHB) in south Wales, Angela Phillips, a senior nurse in the looked-after children and school health nursing service, says: ‘Politically, there’s been a lot of support for school nursing in Wales.’

The new school nursing framework, published by the Welsh Government and NHS Wales in May 2017, sets out a comprehensive view of what school nursing should look like across the country, incorporating the Healthy Child Wales Programme. That the government is behind it is good, says Angela, although the framework has brought new challenges and responsibilities, including a new school entry review (a questionnaire for parents) – ‘with no additional resource, shall we say. Although some health boards in Wales (including ABUHB) have employed immunisation teams and this has been beneficial.’

‘I suppose it’s a question of how you make a very small service go a long way,’ Angela says. ‘In our health board, for instance, every year group is about 6500 children. So at reception age, we’re seeing 6500 children a year to measure them, test their vision and do the entry review on them. And we immunise around 42,000 children a year. On top of that, if you’re trying to get public health messages through to the population… it’s a big ask for such a small service to do that. So I think it’s about school nurses supporting schools to get those messages through and using services more efficiently. With the surveillance screening-type tasks and immunisation, we need an effective skill mix so we’re not using specialist practitioners in those sorts of roles. We are moving towards that in Wales.’

This sentiment is echoed by Margaret Bunting, a lead nurse for school nursing at the Southern Health and Social Care Trust in Northern Ireland. ‘Currently the Public Health Agency is writing a paper on the development of school nursing services. It’s looking to streamline the services across the five health trusts,’ she says. 

She adds that a similar review was carried out recently for health visiting, which had positive effects on funding. ‘We are looking at trying to develop the services and maybe be more defined about what school nursing is,’ she says.

In Scotland, meanwhile, there’s a feeling that school nursing is at a turning point for the better. ‘Historically in Scotland, school nursing was a diminishing service,’ says Annie Hair, a senior nurse and chair of the CPHVA’s occupational professional group for health visiting in the UK. ‘School nurses had ceased to be recognised as specialist community practitioners, and the SCPHN course was no longer offered in Scotland.’ In some areas, the job titles ‘school nurse’ and ‘health visitor’ had been largely superseded by ‘public health nurse’.

This led to recruitment problems as the number of Band 6 qualified school nurses dwindled. ‘There hadn’t been a course for a number of years, so school nurses were recruited at Band 5 – staff nurses – to deliver for school-age children,’ says Annie. ‘A lot of their role was taken up with immunisation and child protection. There had been a veer away from health promotion and drop-ins in schools.’

In 2013, the Scottish Government issued a chief executive letter advising NHS boards that the school nurse role should be reintroduced as a SCPHN qualification in school nursing, that health visitor roles should be enhanced and refocused, and a programme of training – the reintroduction of the SCPHN-SN course – developed. ‘We were quite excited about that because it put school nursing back in recognition,’ says Annie. ‘Various national groups were set up to plan the future services and research the evidence base for school nursing practice.’

One of the three Scottish universities given the task of re-establishing the SCPHN school nursing course is the University of the West of Scotland. Dr Ruth Astbury is the programme lead for its PG Dip SCPHN school nursing programme. ‘It is a very positive move because the role of the school nurse is changing in Scotland in line with current need,’ she says. ‘Much more emphasis is laid on supporting the most vulnerable of our children and young people and their families, particularly with their mental health and emotional wellbeing. Our new programme is preparing the current and future workforce.’


Case study: Vital help

A parent reveals the ‘added value’ of school nurses

Peter* and his husband adopted two brothers aged three and five in 2014. ‘The boys came from a chaotic home and we didn’t have accurate health records for them,’ Peter remembers.

When the boys started school and nursery in south London, they met their school nurse. ‘She was so impressive: she knew all the kids’ names,’ Peter says, who was concerned there was no record of the boys’ immunisations.

‘The nurse said “leave it with me”,’ he says. ‘She checked with the boys’ previous GPs and got accurate immunisation records. Now they’re fully up to date with their jabs. It’s really comforting to know there’s a health professional attached to their school who knows their background well.’

*Name has been changed to protect the children’s identity


 

A different picture

Despite some flaws, a cautiously optimistic and relatively cohesive picture is being drawn by school nurses in Scotland, Northern Ireland and Wales. Head south of the border to England, however, and that picture fades. For example, just under two years ago in Cumbria, the children and families services were targeted to make year-on-year savings of £750,000. In May 2017, school nursing was cut altogether. No school nurses were made redundant, but they were redeployed in other teams.

‘The model we deliver was changed,’ explains Jane, a member of the health visiting team (and whose name we have changed for anonymity). ‘Now there are two services: the Universal Service, which targets under-fives but doesn’t include child protection work; and the Strengthening Families Team, a 5 to 19 service that still delivers immunisations but which also covers all children who are on a safeguarding plan, including under-fives.’

 Jane says that both teams now have higher caseloads. ‘And the people in Strengthening Families are pretty stretched because they’re covering wide geographic patches that would have been covered before by the local school nurse or health visitor – this is a large rural area. GPs are struggling a bit to know where to refer people to because they used to be able to refer to the school nurse. There is now an online counselling service but obviously if you’re a five-year-old you’re not going to be accessing that.’

Does she feel that young people have suffered from this change to the service? ‘It’s an unknown quantity at the moment,’ Jane says. ‘We haven’t had time to measure any outcomes. The jury’s out.’

Some local authorities in England clearly appreciate the value of school nursing services. Claire Elwell, a school nurse in Sunderland and CPHVA Executive member for the North East, says: ‘In my area they certainly want the school nurses out there because it’s a good value service when you consider how they’re able to network and in the schools. What we can deliver with little staff is pretty good.’


School nursing: What the governments say

Northern Ireland 

Charlotte McArdle, Northern Ireland’s chief nursing officer, says: ‘Our school nursing workforce has a vitally important role in contributing to the health and wellbeing of our children and young people. Therefore I see the school nursing specialist practice programme [commissioned by the Department of Health and delivered by Ulster University] as a very important and valuable programme for the implementation of Health and wellbeing 2026: delivering together. School nurses are well placed to lead the changes needed.’

Scotland 

‘School nurses are an integral part of the NHS workforce, playing a vital role in supporting children, young people and their families, especially those who are vulnerable,’ says a Scottish Government spokesperson.

‘That is why we are refocusing their role to work especially with those who most need their support. 

‘We have recommended that NHS boards and integrated joint boards develop teams that enable school nurses, health visitors, community children’s nurses and allied health professionals to work together aiming to improve outcomes and services for our young people.’

Wales 

‘There is an ongoing need to ensure that we commission enough school nursing places,’ says Rhiannon Beaumont-Wood, executive director of quality, nursing and allied health professionals at Public Health Wales.

‘In May last year, the new school nursing framework expanded the role of secondary school nurses to include partner primary schools. This means that all schools in Wales now have a dedicated nurse. 

‘School nurses need to keep abreast of new and emerging communicable and non-communicable threats to health, and ensure they keep their knowledge and skills up to date to respond appropriately.

‘School nurses are well placed to provide accurate information and advice on a range of health and wellbeing issues to both pupils and teaching professionals.’

England 

‘Local areas are determining how many school nurses they need and what the skill mix should be,’ says Wendy Nicholson, national lead nurse for children, young people and families at Public Health England.

‘That’s down to local discretion. In addition, we’ve now got school nurses employed by social enterprises and local authorities, and those numbers won’t be captured in the electronic NHS staff record.

‘We know that there are challenges due to austerity. But that has presented us with opportunities to reformulate what the school nurse offer is, to work very closely with commissioners in local authorities and design exciting service models that are innovative, creative and adaptable. School nurses have been able to shape their roles.’


 

The key to success?

Several of the school nurses spoken to agree that measuring outcomes is going to be key to the future of school nursing. Part of Ruth’s work at the University of the West of Scotland will be to develop an evidence base to prove the effectiveness of their work. ‘We need to develop a clear research programme that shows the clear added value of having a school nurse for children and young people,’ Ruth says.

‘School nurses are generalists,’ adds Claire. ‘A bit like a GP, only we’re generalists in public health and early intervention. We work with parents as well; if there are issues with them we take it up via safeguarding. We open many a can of worms.’

Claire recently left school nursing to work in looked-after children’s nursing, but says: ‘My passion’s basically school nursing. I love an underdog and school nursing is definitely that.’ The challenge for the profession, then, in a budget-restricted NHS, is to shake off that status – and prove its worth.


References

Connett, D. (2017) School nurse shortage 'putting children's lives at risk'. See: theguardian.com/education/2017/aug/25/school-nurse-shortage-putting-childrens-lives-at-risk (accessed 15 January 2018).

NHS Workforce Statistics. (2017) NHS Hospital & Community Health Service (HCHS) monthly workforce statistics - Provisional Statistics. See: digital.nhs.uk/media/34068/NHS-Workforce-Statistics-August-2017-Staff-Group-Area-and-Level/xls/NHS_Workforce_Statistics__August_2017_Staff_Group__Area_and_Level (accessed 16 January 2018).

NMC. (2017) NMC data. NMC: London. Provided by Press office, Ben Jackson.

Scottish Government (2013) Public health nursing services – future focus, CEL13, Scottish Government, 28 June 2013.

Welsh Government. (2017) A school nursing framework for Wales. See: http://gov.wales/docs/phhs/publications/170523schoolnurseen.pdf (accessed 16 January 2018).

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