A SCOPING REVIEW OF HEALTH VISITING AND SCHOOL NURSING

Transcription

1 ANEURIN BEVAN HEALTH BOARD A SCOPING REVIEW OF HEALTH VISITING AND SCHOOL NURSING EXECUTIVE SUMMARY 1. Health visiting and school nursing services differ from other health services in that they are concerned predominantly with the well population to whom they offer an early intervention and disease prevention service at individual, family and community levels. Their focus on health rather that illness, their knowledge and skills around prevention and health promotion and their location in communities makes these services an important resource for achieving the WAG new agenda for their health services. However in recent years the imperative of acute and treatment-orientated services, safeguarding and child protection matters and the misunderstanding of the work and effectiveness of these roles has led to much disinvestment and as Flying Start shows, needs a reorientation of priorities and the work into new models of practice. 2. This scoping study commenced in September 2010 to agreed terms of reference with the aim of the work being to guide the development of a vision for the future delivery of health visiting and school nursing services within ABHB and to identify the steps and changes required 3. The work took a bottom up approach meeting with as many frontline practitioners from the health visiting and school nursing service as time allowed as well as with their manager s and other internal and external stakeholders. Also reviewed was a range of written information obtained from ABHB and more widely as shared and discovered on the internet. 4. The work included: a. a scoping of existing professional health visiting and school nursing structures and processes across ABHB b. a review and evaluation of existing professional structures in health visiting and school nursing across ABHB in the context of WAG policy and guidance c. undertaking of comparative benchmarking with health visiting and school nursing services in other organisations in Wales (it was agreed the supporting manager would undertake this part of the work)

2 d. making of recommendations for future structure and processes in health visiting and school nursing across the organisation with reference to WAG policy and professional guidance The professional practice of health visiting and school nursing 5. Health visiting as a profession has a long history having developed from the philanthropic public health movement of the second half of the nineteenth century. Traditionally health visiting service provision has been universal, non-stigmatising and offered to all families whatever their circumstances. Unlike the majority of other community based services, health visitors work predominantly with the well population offering a health promotion and disease prevention service to the individual, their families and the communities in which they live. Frequently the service is the link for families to other services and health visitors and their school nurse colleagues are skilled at networking and forming alliances with other statutory and voluntary organisations. 6. The work of the health visitor (suggested as relevant to school nursing)is based on four principles established by the Council for the Education and Training of Health Visitors, then their statutory body, in 1977 (CETHV 1977). They were reviewed by the Health Visitors Association (now the CPHVA) in 1991 and found to be as relevant at that time as when they were first published (Twinn and Cowley 1992). They have recently been further reviewed by the CPHVA and are again still felt to be relevant to health visiting (Cowley and Frost 2006). They were used by the UKCC (United Kingdom Central Council for Nursing, Midwifery and Health Visiting), now the Nursing and Midwifery Council (NMC), to form the basis of the competencies for standards of proficiency for specialist community public health nurses and the third part of the nursing and midwifery register (NMC 2003, NMC 2004). The principles are, the search for health needs the stimulation of the awareness of health needs the influence on policies affecting health the facilitation of health enhancing activities

3 7. Since 1974, when health visiting along with school nursing, became part of the NHS, having previously been under the control of local authorities, frequent discussions have taken place within primary care as to their role and function, their relationship to general practice and other community based nursing services and whether within GP attachment, health visitors can exercise their public health role, concern being expressed that the role of health visitors was becoming medicalised and losing its public health focus. Thus the required return to a wider community and public health perspective and active working with Sure Start Children s Centres and Flying Start Centres has been welcomed by many health visitors who are keen to return to their public health roots but often fearful as to whether they have the skills or indeed whether there will be the organisational opportunities to do so (DH 2001, Rowe 2001). 8. The provision of statutory health services for school aged children has a long history and dates back to the end of the nineteenth/beginning of 20 th century. The School Health Service is the oldest establish National Health Service having developed in the early 1900s as a result of the poor health of recruits to the Boer war. School nursing like its sister profession of health visiting, has traditionally been universal, non-stigmatising and offered to all children, young people and their families whatever their circumstances and similarly, working predominantly with the well population, offering a health promotion and disease prevention service to the individual, their families and in the schools that they attend. Frequently the service provides the link for schools to other services and school nurses are often skilled at networking and forming alliances with other statutory and voluntary organisations. 9. For school nursing, like health visiting, becoming part of the NHS in 1974 brought many changes and frequent changes in fortune and function (DeBell and Tompkins 2006). One Wales published in 2007 made the commitment that every secondary school in Wales would have access to one, full time and all year round, qualified school nurse. In 2009 with the publication of a Framework for School Nursing, the WAG has taken forward this commitment and provided resource to make it a reality.

4 10. For health visitors and school nurses, their flexibility and adaptability is both a strength and a weakness, as it leaves them vulnerable to other s interpretation of their role and has often meant they have been inappropriately used to undertake other s work, leading to arguments both within and outside the profession about their roles and responsibilities (Cowley et al 2000, DeBell 2000). Both professions often feel misunderstood and undervalued and for many the expectation on them that they will combine wider public health work with either community work across the age ranges or with a traditional caseload and one to one work, is a daunting task and will require, if it is to be successfully implemented, a rethink, refocus and redesign of service delivery toward a team approach across health, social care and education. Partnership and collaboration will be the key to future service delivery, this needing to be a requirement both across professional practice and with the clients and consumers of the service. The current practice of health visiting and the allocation of staff 11. This scoping study was triggered by present national/local changes in Wales and across ABHB. The development of Flying Start was also throwing up some difficulties in that a two tier service was being seen to develop, with Flying Start staff being able and encouraged to work through early intervention and in a primary preventive way when the generic staff were being totally reactive and working in the main with vulnerable families, complex needs and those on the child protection register. There was felt a need to engage all staff and help them feel part of the new agenda and the changes occurring. 12. In chapter 3 in a number of sections especially 3.1, 3.2, 3.5 and 3.6 the perspective of the health visiting staff and the work they do is described, as the consultant understood it from the focus groups and interviews she undertook and the information shared with her. From this work the consultant feels confident in reporting that there are a number of excellent practitioner working for ANHB within the health visiting service and that they are offering, as able, a very effective and safe service.

5 13. What is clear is that the workload levels and experienced need of their caseload/workload is not clearly understood. Issues that require addressing and form part of the recommendations are the inequities being experienced between staff working in the Flying Start service and the generic service, with the need to make this clear to the WAG (this is identified in the WAG interim report of Flying Start 2010); the need for the HB to understand the differences between how primary care/community services work and function and how acute services need to function to deliver safe services; resource issues like lack of IT. 14. A particular issues that will need to be addressed and related to the difference between the experiences of Flying Stat and generic health visitors is how need is defined in terms of deprivation and as a result related to caseload/workload numbers. The actual tool presently in use for generic services, to the consultant does not seem to be as effective as it could be and judgements of vulnerability and need by practitioners themselves seem to be quite subjective. As indicated in section 3.6, the present tool looks at caseload as opposed to the funding module described which first identifies the workload an area could generate. The consultant would recommend the HB looking at the funding model developed by Cowley in 2009 using it in a similar way to London SHA (Cowley, London SHA 2010). This would help in work allocation and in understanding the need for qualified staff and skill mix support. It could also be used to review how the service is organised and to help in understanding whether some areas such as Newport would benefit from a more geographical approach and corporate caseload working. 15. How skill mix is being used is a recommendation as its use needs to be through establishing teams of staff who work together with the families and children on a caseload as in Flying Start. Here a policy is in place for the use of skill mix identifying the role and responsibilities of health visitors and in this case nursery nurses but it is clearly not fully understood or accepted as the audit earlier this year shows. 16. The HB has a number of policies and pieces of professional guidance which direct the work of the generic health visiting teams but they are not being used effectively across the whole of the service. As a result the service offered in different localities or within localities can be very different. This may be due to the identified needs of an area but it is suggested that this is more to do with the time and resources available for staff. It would be helpful to build further on the core programme for the health visiting service to ensure that what is being offered does meet local need.

6 The development of school nursing to meet WAG requirements 17. The publication of A Framework for a School Nursing Service in Wales by WAG in August 2009 paved the way for the much needed development of the school nursing service in order to offer a service which is safe, accessible and of a high standard. As reported the school nurses within ABHB were thrilled at the changes being proposed to their service as a result of the WAG initiative and devastated when they were informed in September 2010 that this may not be possible due to financial constraints. 18. As a group the school nurses clearly work hard to deliver as effective service as possible and work well as a team but as is common with all school nursing service across England and Wales they are under resourced to meet the needs. It is essential that further consideration is given to developing the service along the lines of the WAG Framework. 19. With this group there are also a number of practical issues noted in section 3.3 which if addressed would help their work. Also needing to be addressed further is their integration and linking to the health visiting service, how they can work more closely with GPs and paediatricians as well as how they fit into the management structure and how they are led. Further they have similar needs in terms of IT and resources as their health visiting colleagues. The management and leadership of the service 20. Within the NHS we are now realising the difference between the internally focussed process of managing a service and the externally focussed process of leadership. Management is more about decision making and problem solving on a day to day basis in order to meet measurable outcomes. Leadership provides the on-going vision and direction for development and growth and requires a degree of risk taking and tolerance of ambiguity. When a service is tightly managed and controlled, those within it become disempowered and feel unable to take responsibility and accountability for their actions. With positive leadership innovations occur and practitioners feel empowered to develop their services to meet client and community needs.

7 21. The Health Visitors and school nurses need to be empowered and able to take accountability and responsibility for their actions. ABHB needs to allow them to do so providing appropriate support and guidance. 22. Any future management and leadership structure will need to ensure that senior staff, with a knowledge and understanding of health visiting and school nursing, are leading the service and readily available to practitioners and wider stakeholders to ensure the professions are supported and developed. Integration and partnership working 23. The Children and Young People Partnerships within local authority areas have been established to ensure integration and partnership working across local authorities, health and education; this being one of the main policy areas of WAG. Traditionally health visitors and school nurses would say they have always worked in partnership with their clients and others and that by using the principles of health visiting they attempt to create awareness of health needs and to facilitate health enhancing activities. Obviously doing this and maintaining partnerships is easier for Flying Start teams as they have smaller caseloads and the service has been set up to be a multi agency partnership. Being able to really work in partnership with clients, in the way now required, however requires a very different approach to practice and needs practitioners to feel confident and themselves to be empowered. Effectively working in integrated services requires a similar state of well being and knowledge and understanding of how other services function, are educated and trained and are delivered as well as their customs and traditions. This requires to be addressed before conflicts arise and for those involved to be open and honest with each other, having sophisticated and well developed interpersonal skills.

8 24. There is no doubt that health visitors, school nurses and their team members intend and want to work in partnership with parents and children to ensure they deliver services in a way that meets their needs. The aims of health visiting and school nursing, its principles and the way these staff are trained means they see such a concept as part of their practice. Moving toward greater integration of work with social care and early years education and links with Flying Start, whose philosophy is one of partnership with the local community, can only help this. Safeguarding children and child protection matters 25. Recent national inquiries into deaths of children in both England and Wales have brought an increased focus within health visiting and school nursing practice to child protection and safeguarding matters. The Flying Start initiative is an attempt to refocus the work of frontline practitioners back to early intervention and prevention and the evidence from this work and the initial evaluation across Wales (WAG 2010) would suggest this is happening. However for the generic staff their focus of work remains on vulnerable families and children in need and those on the child protection register. As they report they are reactive in their work having little time for early intervention and prevention. As suggested in the report this needs to be addressed and their role redeveloped in a similar way to that of Flying Start. 26. Although safeguarding children and child protection matters were a feature of the work when talking with frontline staff, it was clear the safeguarding/child protection team were seen as helpful and useful by staff and in discussion with the named nurse it felt she and her colleagues had a handle on matters. There does however need to be clear written standards for safeguarding/child protection together with clear definitions around vulnerability and thresholds Ensuring an effective, competent and educated workforce 27. Today s NHS requires all organisations to ensure their workforce is effective, competent and appropriately educated with the knowledge and skills required and is able to assess the education and updating they need. Organisations also need to ensure they performance manage their staff to identify any ongoing professional needs and provide an annual appraisal using the KSF.

9 28. Safeguarding supervision has recently been adjusted to more effectively meet needs. In terms of professional/managerial supervision some staff are receiving clinical supervision which is generally peer support as well as ongoing day to day support from their managers. The issue of clinical supervision, its nature and who receives it needs to be explored further and is followed through as a recommendation. 29. The discussions with frontline staff around their education and training needs and their ongoing professional updating raised a number of issues and requires further exploration. Again Flying Start staff were receiving some excellent development which needs to extend to all generic staff. 30. The practice teachers across both professions felt they could be usefully used to provide some of the updating for their colleagues as they had the opportunity to liaise with the two Universities and to learn of new research and developments. The provision of resources equipment, IT and accommodation 31. The issue of access to IT and related equipment need to be addressed as a matter of urgency if both services are to be enabled to function effectively. Developing a vision and strategy for the service 32. From this scoping work it is clear that the services of health visiting and school nursing within ABHB require a strategy and vision for the future in line with current WAG policy, especially that around children s services and the emerging professional agenda. This needs to be developed in conjunction with frontline staff.

10 33. Such a service vision is not a static entity; rather it needs to be seen as a dynamic concept and one that continually develops and grows as new policy emerges and needs change. To be effective and ensure health visiting and school nursing practice remains in line with client need and the changing NHS requirements, the present vision and ideas presented in this report will need to be constantly reviewed if the two services are to remain dynamic and valued. Responding to change and developing its practice to do so, is something health visiting and school nursing has a past history of doing, but as is evident here it requires an appropriate management and leadership structure to be enabled to do so. 34. To develop the required new model and meet the recommendations made, a planned change management programme will be required, delivered in a way that recognises individuals different reactions to change. It will need to be one that helps health visiting and school nursing team staff to learn to anticipate change, adapt to change as quickly as possible, enjoy it and be ready in today s NHS world to be able to change quickly, again and again (Johnson 1998). Conclusion 35. Those reading this executive summary or the whole report are asked to see the findings reported as the thoughts and the interpretations of the external consultant as she met with the health visiting and school nursing team staff and other staff within Aneurin Bevan Health Board to complete the scoping work. Her thoughts have also been informed by her reading and by the interviews and discussions she has had with other stakeholders both within the HB and more widely across the geographical area of ABHB. In raising issues and commenting both positively and sometimes in not such a positive way, blame and praise is not placed in any one area or on any one person. All staff met both in frontline practice and in management and leadership roles are clearly working hard to offer high quality children and family services to those living within the HB geographical boundaries. There is much work to do in developing and modernising the service. In the future with the constant changes within the NHS, it is likely any modernisation will never be complete. By following the recommendations made below and by continuing with the excellent work already in progress, it is believed the right change will occur, the enthusiasm for that change be harnessed and maintained and the health visiting and school nursing team staff become and remain empowered and able to take responsibility for their own development and practice.

11 RECOMMENDATIONS The current practice of health visiting and the allocation of staff Recommendation 1 A core specification for generic health visiting practice, in line with the WAG specification for Flying Start, needs to be developed for commissioning purposes in order to ensure there is understanding across ABHB of what the service can and should be expected to offer. Conversely staff within the health visiting service need to be clear what is expected of them, so they can more clearly identify when they are not meeting the expectation and be performance managed on its delivery. The development of the school nursing service to meet WAG requirements Recommendation 2 ABHB needs to further consider the WAG Framework for a School Nursing Service in Wales and consider how it can make the changes required in order to deliver a safe, accessible service of a high standard and ensure there is a minimum of one qualified school nurse per secondary school by May The management and leadership of the service Recommendation 3 Arrangements should be put in place to ensure health visiting ad school nursing services receive effective professional leadership and support to provide the strategic direction and professional development required to implement policy and the subsequent changes needed. At the same time an appropriate management structure will be required to ensure effective day to day functioning of the service.

12 Integration and partnership working Recommendation 4 Further work needs to be undertaken to ensure the integration and partnership agenda, across all services, is functioning effectively both internally within ABHB and externally across into the wider health service, the local authority, social services, education and into the voluntary and charitable sectors. Safeguarding children/child protection matters Recommendation 5 ABHB needs to clarify its expectations of health visitors, school nurses and their team members in terms of safeguarding children/child protection matters ensuring all involved both internally and externally are clear about roles and responsibilities, what is required, what they can expect from and what can be achieved by health visiting/school nursing team members Ensuring an effective, competent and educated workforce Recommendation 6 The education and development needs of health visiting and school nursing team staff should be reviewed to ensure all staff are able to access the education and development they require to deliver effective, evidence based practice. The provision of resources equipment, IT and accommodation Recommendation 7 A full review and risk assessment of the resources available to health visiting and school nursing staff and their managers is required, to include accommodation, IT resources, communication resources.

13 Developing a vision and strategy Recommendation 8 In order to continually develop practice and deliver effective services which are in line with the identified needs of clients and the ever developing policy agenda, a dynamic vision for the future delivery of health visiting and school nursing services is required. Conclusion This report provides a picture of the present position across the services of health visiting and school nursing within Aneurin Bevan Health Board. However some positive aspects are also identified, especially in respect of developments around the Flying Start service. In analysing the information gathered, the changes required to meet the WAG policy agenda and required professional developments are identified and pulled together into a number of recommendations. Margaret Buttergieg