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Developing public health provision for vulnerable young people

01 January 2016

Heidi Fewings reports on the development of a specialist school nurse service aimed at vulnerable children and young people in Hull.

Guidelines

Heidi Fewings
Support services health team leader, North School health team leader

Correspondence: h.fewings@nhs.net

Key points

  • Supporting vulnerable young people through a single team can strengthen multiagency working and enhance care
  • Involving young people in the wider agencies, voluntary organisations and community groups has ensured that staff can engage the specialist client group
  • Understanding our wider agencies and voluntary and community groups working with children and young people is key to ensuring sustainable outcomes
  • As resources and funding are reduced, think outside the traditional delivery models and utilise expert skills to transform services
  • Service development and change need to continue to ensure evidence-based practice to meet the needs of the young people in the modern changing world.

Abstract

Engaging vulnerable children and young people can be a challenge. This article reports on the development of a specialist school nurse service, known as Support Services Health Team, aimed at the most vulnerable children and young people in Hull. The aim was to provide public health support and coordinate healthcare to children and young people in the looked after system, those in pupil referrals units, home educated and those outside of the educational system (missing from education). This innovative approach to addressing the health needs of this population helped to establish firm networks across the city of Hull, reduce duplication of support being offered and avoid young people slipping through the systems. The team has a sound knowledge around health trends for young people, social groups and hotspots where they are at risk across the city. They have created a presence in the city where professionals and young people are aware of them and the service offered. Clear pathways have been established on intervention starting with the completion of a comprehensive health needs assessment and care plan. A creative approach to supervision has been established to ensure staff do not feel
overwhelmed and that they are evidence-based in their approach to intervention and advice offered.

Keywords: Vulnerable Children and Young People, School Nurse, Looked After Children, Education, Service Redesign


    Introduction 

    Marmot (2010, p39) focused on the “causes of the causes” of health inequalities, the aim being to intervene early to avoid ill health in later life. Similarly, the Department of Health (DH, 2013) identifies the need to focus on early intervention to achieve health improvements and better control of the wider determinants of health. School nursing teams, due to their ability to access and engage with the school aged population, are able to lead and contribute to improving health outcomes for children, young people and their families. However, growing demands and austerity measures have resulted in a lack of investment in school nursing services over the years. This article will discuss an innovative approach to addressing public health needs and coordination of healthcare to the most vulnerable children and young people in Hull. This article will only focus on the work completed in the newly formed team and not on the wider school nursing teams in the city of Hull.

    In Hull, a lack of financial opportunity did not stop the school nursing service from being creative and looking at how services may be delivered more efficiently. City Health Care Partnership (CHCP) CIC, a growing co-owned for better profit business, provides a wide range of health and care services to more than half a million children, young people and adults across numerous geographical areas. One of the main values of the organisation is creativity and innovation.

    In 2011, the director of children and young people’s services encouraged specialist public health practitioners (school nursing) working within the school nursing workforce to present evidencebased ideas about how best to deliver services for children and young people aged 5-19 in Hull. The aim of the direction was to reshape the existing experienced workforce, eliminate outdated practices, and redirect skills and expertise to ensure the service could be delivered more efficiently. Following this direction, any specialist public health nurse who had ideas were given an opportunity to present at an event arranged by the director. The audience of this event included the director, the senior operations manager and clinical services manager in children and young people’s services, the designated nurse for safeguarding, and the school nursing staff. The audience asked the presenters questions and had an opportunity to challenge any proposed ideas. On completion of the presentations the management team created three proposals using ideas from the presentations to restructure the school nursing workforce. These were then sent to the school nursing workforce to vote on which structure staff preferred. By utilising existing interests and skills in this area to devise a plan to deliver a service to the most vulnerable children in Hull, this presented a unique opportunity.

    The proposal was for the most vulnerable children and young people across the city to be brought together under the care of one city-wide team. The team was created as an extra team within the school nursing workforce with the service intended to embrace children and young people not attending mainstream education provision and those aged 5-19 who were in the looked aftercare system. Historically, services provided to these individuals were fragmented and lacking in continuity of care to individual children and young people.

    Hull has three localities, east, north and west, and the school nursing service has a team in each. Historically, children and young people were allocated to the caseload of the locality teams based on the postcode of the home they lived in, if they were home educated, or on the location of the pupil referral unit/alternative educational provision. The complex problems, experienced by vulnerable young people can significantly impact on their engagement in education, sometimes resulting in them being transferred to alternative provisions, eg pupil referral units (Public Health England and Association for Young People’s Health, 2014). If a coordinated multi-agency approach to supporting the individual’s needs is not drawn up then the alternative education placement may break down and the young person is moved to another educational placement. This is what was happening in Hull resulting in young people frequently being passed from caseload to caseload.

    Historically, looked after children’s health assessments were completed by nurses within the locality teams where they lived if under five, and what school they attended if over five. A looked after health assessment is a comprehensive health needs assessment completed annually if the child is over five and every six months when under five, something that is a statutory requirement for children and young people in the looked after system (Department for Education and Department for Heath, 2015). A care plan is created that includes care provided from health but also from other agencies ie education or social care.

    If a child or young person’s foster placement broke down or they moved, the child/young person was transferred to a locality team often outside of their current residing locality. This meant the child/young person had to be allocated another nurse and then their health assessment was completed by another unknown professional. This fluid process involved a constant movement between caseloads across the locality teams, resulting in few vulnerable young people being seen or supported. In January 2012, all the pupil referral units, looked after children, home educated and young people who were not in any form of educational provision became the caseload of the newly formed team. In addition to the newly formed team, the school nursing services continued to work in three localities covering the core service provision and safeguarding commitments.


    Background 

    Barnes et al (2011) completed a study to understand vulnerable young people’s risk-taking behaviours and aimed to conclude how services can support young people to improve their aspirations and achievements. The main conclusion was that to reduce the number of young people not participating in employment, education or training (NEET), services must be reformed to offer early interventions. Barnes et al (2011) focused their study on specific vulnerable groups, acknowledging that a single disadvantage in a young person’s life can create difficulties, multiple problems and lead to harmful and costly outcomes for the young people, economy and society as a whole. Given that a single disadvantage can lead to multiple problems for one individual, the impact on society may be huge when for example, it has been identified that Hull has 32.6 percent of children aged under 16 years of age living in poverty, which is worse than the England average of 19.2 percent (Public Health England, 2014).  In addition, the health and well-being of children in Hull is generally worse than England’s average (Public Health England, 2014).

    It is well documented that early intervention is the key to healthier adults and families (Marmot, 2012; Chief Medical Officer, 2013). However, in Hull we have a large proportion of families where interventions were not offered or were offered and delivered without success, this is evident in the numbers of children and young people in the looked after system, with Hull being significantly higher than England’s average of 60, at 116 (Department for Education, 2013; Public Health England, 2015). The lack of successful interventions results in children and young people with outstanding health needs engaging in risk-taking behaviours with a lack of boundaries and supervision to sustain mainstream education environments.

    The aim of the newly-formed school health team was to target these children and young people by offering structured health needs assessments, identifying needs, acknowledging expressed needs and providing support or referral on to specialist services. The aim being to coordinate healthcare for individuals by utilising the expert knowledge of the area and health services available for specialist identified health needs. The newly formed team was called the Support Services Health Team.


    Setting up the service 

    Initially, the support services health team started with just 45 hours per week of school nursing time due to the financial constraints on the wider school nursing service. This was a challenge but the new service needed to be set up and started to ensure it could feasibly continue as a specialist service. In the early stages, all school health professionals were asked to identify children and young people on their caseloads who met the criteria of being educated outside of mainstream education and those children and young people who were in the looked after system. Cases were transferred from the locality school nurse teams to the new service and allocated according to their level of need.

    A major discrepancy discovered at this point was the difference between the number of cases known to the school nursing teams and the actual number of children and young people outside of mainstream education provisions, with the number being a lot greater than expected. This situation had arisen due to a lack of communication over the years between health and education, and a failure to correctly coordinate the admissions and discharges of children and young people into pupil referral units, wider training provisions or designated as being educated at home. In addition, children and young people who move out of mainstream education tend to have additional impacting factors that result in them moving from one provision to another on a frequent basis (Public Health England and Association for Young People’s Health, 2014). Walker and Donaldson (2010) highlighted that teachers and other educational services were best placed to identify the early signs of risky behaviours in individuals. However, teachers were identified as not always wanting to engage with issues they referred to as welfare rather than educational issues. Kennedy (2010) supported this with his findings from professionals that some head teachers and school staff are reluctant to make the necessary commitment to identifying young people’s needs beyond education.

    The initial priority was to engage with these alternative provisions eg pupil referral units, to ensure regular dialogue and multi-professional working was to be implemented. Local provisions stated that a lack of clarity around which nurse should be contacted had resulted in unclear working relationships. Alongside this, it was acknowledged the administrative processes needed to be managed better, resulting in an administrator being allocated to the team to maintain a regular liaison with all the educational providers in Hull, who were supporting children and young people outside of mainstream educational environments. The administrator’s main role was to support the administration of the newly-formed team and to make regular contacts with the providers and update the health system.

    It was decided the team would be colocated with the safeguarding children’s team and be based within Hull’s multiagency safeguarding hub (MASH). This has allowed the team to promptly address safeguarding issues and general concerns, and has also allowed social care and police to request information or task us to follow up on health concerns. The placement of the team has promoted both multi-agency working and understanding of job roles.

    The team started with minimum staff and has now expanded through recruitment and selection. The first stage of recruitment saw a rise from 45 hours to 120 hours of nursing time and 37.5 hours of support worker time (this was a nursery nurse with an interest in adolescent health). The second stage resulted in a further 75 hours of nursing time and 37.5 hours of support worker time. All staff members were recruited with a young person on the selection panel. The young people were known to the service and were selected through a local Young Voice in Care (YVIC) group. A formal reference of their conduct during the interviews was completed for their work portfolios. The young people prepared a question for the interviews with support from the team leader. The contribution of the young person ensured the staff members were able to demonstrate that they could engage with a young person and that the young person felt they would engage with them. Marrow and Graham (2010) describe the involvement of children and young people in the recruitment of staff as adding value, sending the message to young people that they have an important contribution to make.


    Identifying needs

    Discussions were held by the team leader with all pupil referral units and individual educational establishments and provisions providing education outside of the mainstream environment. Basic referral criteria and pathways were developed with referral forms to be used for young people who required health support or advice. In addition to referrals, work around safeguarding issues and processes for the children and young people in the looked after system continued as per existing local safeguarding children’s board (LSCB) protocols.

    To ensure young people were aware of the Support Services Health Team, leaflets and posters were created with the team’s mobile number and were distributed to all the provisions. Alongside this promotional work, sex and relationship education, drug awareness and child sexual exploitation training, to name a few, were delivered within the pupil referral units and alternative educational establishments provisions. This was a further opportunity to promote the new service, allow the young people to see a familiar face and distribute the contact details for young people to make contact with the service if they had any health concerns. This work continues and is delivered by our health and wellbeing support workers.

    Engaging the young people was key to identifying needs as they hold the power to talk negatively or positively about their experience of a service. Negative or dismissive feedback will influence other young people, which in turn will result in them not seeking support from or accessing the service. Therefore, the team started to visit local youth groups, a Youth Parliament and a local Young Voice in Care group. Alongside this increased visibility, the team leader secured a position on a citywide education-led Fair Access meeting, held monthly, where young people were discussed when they were either excluded or needed to be educated in alternative provisions due to their behaviour, conduct, health and/or attendance. The information is sent via the educational welfare system to the team leader prior to the meeting and an update of the decisions of the meeting is sent via e-mail following the meeting. This provides up-to-date intelligence around the young people’s school moves and allows the school nurse workforce and support services team to maintain the caseload with real-time information. Furthermore, it enables the chair of the meeting to inform health of any known health needs that may require follow up.

    As the work evolved it became apparent a high percentage of the young people on the caseload were known in the local Missing at Risk of Sexual Exploitation arena – a meeting held every six weeks to discuss vulnerable young people who were regularly missing from their home or their children’s home/foster placement and those that were at potential risk of exploitation. The team leader became the dedicated staff member who attended the city’s operational Missing at Risk of Sexual Exploitation meeting, representing health. This increased the Support Service Health Team and wider school nursing team’s awareness of vulnerable groups of young people and those who required health support/intervention. The team leader updated the school nurses outside of the support services health team of any young people discussed who were on the caseload of the locality school nursing teams. The team leader also linked into local police intelligence with police informing them of risk hot-spots (eg addresses providing illegal tattooing or selling legal ‘highs’ to under 16s). Multiagency work is ongoing around data sharing of individual young people.


    Measuring outcomes  

    Following the review of school nursing, which took place in January 2012, the service migrated onto an electronic care record keeping system, SystmOne, in September 2012. This was positive progress for the team as it allowed the team’s performance to be monitored directly from patient records. In the initial stages of service development this was being done in paper form. Due to the nature of the interventions provided, the service will have directly assisted in reducing some of the local targets eg teenage pregnancy, admissions to the accident and emergency department, and reduction in alcohol and drug use. Health needs assessments undertaken by the team have resulted in young people being referred to specialist services. These targets can be captured in the support offered to the young person as part of the health needs assessments and follow up support.

    A professional network has been created and strengthened ensuring all agencies are aware of the team and that the team are aware of other agencies/projects that are available to support vulnerable children and young people. The service, because it takes responsibility for all vulnerable children and young people, has enabled trends within this population, risk hot-spots to be identified and links to be made across the city, with various groups of young people involved in these and other practices. This has allowed our intelligence of young people’s needs and risks to develop.

    One of the main achievements in the team is that those ‘hidden’ children now have access to a comprehensive coordinated service, and the children and young people have an allocated health lead who remains allocated regardless of their address or provision. The knowledge base around this cohort of children and young people has increased, which has allowed the service to align to the needs of this population.


    Clinical issues

    The Care Quality Commission (2012, p4) defines clinical supervision as an “opportunity for staff to reflect on and review their practice, discuss individual cases in depth and to change or modify their practice and identify training and continuing development needs”. Clinical supervision was provided alongside safeguarding supervision by the team leader to the nurses. The team leader received clinical supervision via their line manager and safeguarding supervision from a safeguarding practitioner within CHCP’s safeguarding children’s team. The aim of supervision is to ensure the service provides high quality care and that the service users’ interests are promoted and protected (Morrison, 2005). The newly-formed team’s caseload was one of the highest held caseloads in the city. In addition to the high numbers, the majority of the cases were high need, and therefore required a discussion at supervision to ensure safe practice was maintained. It is recommended that cases that require ongoing support, plus a range of additional services, to address complex needs should be allocated to the Universal Partnership Plus caseload and should be discussed every three months in supervision (Department of Health and Public Health England, 2014). It was an impossible task to discuss all cases on an individual basis and a more creative approach was required. An annual diary of supervision was created for cases to be discussed on a one-to-one basis as part of a peer supervision session and a wider discussion with other health professionals involved in individual client care.

    As the team expanded the caseloads per individual reduced, however, the numbers remain high. A major downfall in terms of service planning is the identification of the needs of the population; the more needs that are identified the greater the workload. It is heavily researched that vulnerable young people will go on to develop multiple vulnerabilities that in turn impact on the amount of work required to support an individual (The Centre of Social Justice 2013, 2015; Public Health England and Association for Young People Health, 2014; Clements 2013). Alongside the extensive health support the children and young people in the looked after and social care system require, they also have a large number of meetings that need to be attended, all of which take up time and resources.

    The future  

    As services evolve the need to stay focused on service users’ needs, while trying to be realistic around cost efficiency and new contracts being proposed by local authorities results in constant changes to the way services are delivered. The need to continue to be creative and innovative will ensure the service continues to meet the needs of the most vulnerable young people while working to cost efficiency plans. As a cohort of young people, their needs are complex and over recent years greater emphasis has been placed on young people at risk of sexual exploitation. This is the current agenda, however, time will produce new trends and risks for young people and their families. Supervision is an essential process that provides staff with quality support and guidance to ensure standards of care delivery are safe and of a high quality. As new issues arise, staff need to continue to update their skills and knowledge and ensure that the voice of the young people continue to shape best practice.

    Conclusion 

    The service is now well established and well known within Hull’s networks of services supporting children, young people and their families. It has enabled children and young people to receive a consistent service that is in tune with the needs of the most vulnerable communities. The foundations have been set and the aim is to build upon them to ensure services for vulnerable children and young people in Hull are some of the best in the country.


    References

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    Care Quality Commission (2012) Supporting information and guidance: Supporting effective clinical supervision. Available from: http://www.cqc.org.uk/sites/default/files/documents/20130625_800734_v1_00_supporting_informationeffective_clinical_supervision_for_publication.pdf [Accessed April 2015].

    Chief Medical Officer (2013). Annual Report of the Chief Medical Officer 2012Our Children Deserve Better: Prevention Pays. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/255237/2901304_CMO_complete_low_res_accessible.pdf [Accessed April 2015].

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