CHILDREN AND YOUNG PEOPLE S OVERVIEW AND SCRUTINY COMMITTEE 14 th JANUARY 2014

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1 CHILDREN AND YOUNG PEOPLE S OVERVIEW AND SCRUTINY COMMITTEE 14 th JANUARY 2014 UPDATE ON SCHOOL NURSING Report from: Dr Alison Barnett, Director of Public Health Author: Dawn Hollis, Senior Public Health Manager Commissioning and Assurance Summary This report provides information on the commissioned public health service of school nursing. The report provides an outline of the context of school nursing within the Healthy Child Programme (age 5-19), as well as details of the current service provided. The report then discusses the impact that school nursing has on children s health and safety and on its contribution to the public health outcomes framework and the Council Plan 1. Budget and Policy Framework The Health and Social Care Act 2012 transferred public health responsibilities from Medway PCT to Medway Council. This new public health responsibility includes the Healthy Child programme (age 5-19 years) and the commissioning of the school nursing service. School nursing is commissioned from the Public Health Grant, issued to Local Authorities. The Public Health Outcomes Framework sets out an overarching vision for public health, along with outcomes and indicators to be used to demonstrate achievement. The two high-level outcomes are; increased life expectancy and reduced differences in life expectancy and healthy life expectancy between communities Four domains then identify various indicators to help focus understanding of how services are contributing to public health outcomes (see section 2.4 for detail). The Healthy Child Programme (HCP) (DoH 2009) then sets out the good practice framework for prevention and early intervention services for children and young people aged 5-19 and recommends how health, education and other partners working together across a range of settings can significantly enhance a child s or young person s life chances. The school nursing service is a key public health service through which the HCP (5-19) is delivered.

2 2. Background Since April 2013, local authorities have been statutorily responsible for commissioning and delivering public health services for children and young people aged This includes providing prevention and early intervention services, addressing key public health issues such as sexual health, emotional health and wellbeing issues, obesity, drug, alcohol and tobacco misuse and delivering the Healthy Child Programme (5-19). The importance of such a service is highlighted in Getting it right for children young people and families (DoH 2012). The service aims to improve health and reduce health inequalities by working with individuals, families and communities promoting health, preventing ill health and in the protection of health. Providing a child-centred approach, school nurses work with individuals, groups, families and communities in schools, homes and in wider community settings. Across Medway, school nursing teams work within a multi-disciplinary and multi-agency environment. 2.1 What is a school nursing service? School nurses are qualified nurses with additional specialist training in the public health needs of school aged children, including signposting and referring to other services where appropriate. The role of a school nurse involves a range of skilled activities and communications at individual, group and community levels. It includes health promotion, advice, signposting to other services, active treatment/procedures, education, support, protection and safeguarding. The school nursing service is responsible for delivering programmes or interventions that contribute to the improvement of health outcomes, including reducing childhood obesity, reducing under 18 conception rates, reducing the prevalence of chlamydia and support for emotional well-being and good mental health. Significant work is currently underway at national level to develop a national service offer for schools nursing, to complement that of the health visiting service. 2.2 The school nursing model The emerging national school nursing model is based on four levels of interaction with the community, families and individuals, with safeguarding as a theme through all levels. The four levels outline the continuum of support which children and young people can expect to receive through the school nursing services and multi-disciplinary working. 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 co-ordinating services (Universal Partnership Plus). The model aligns with the new model for health visiting services to provide continuity of services from 0-19.

3 Diagrammatic Representation of School Nursing Service Model Community Level School nurses have an important public health leadership role in the school and wider community for example contributing to health needs assessment, designing services to reach young people wherever they are, providing services in community environments and working with young people and school staff to promote health and wellbeing within the school setting. In particular school nurses work with others to increase community participation in promoting and protecting health thus building local capacity to improve health outcomes Universal Level School nurses lead, coordinate and provide services to deliver the Healthy Child Programme (HCP) for 5 19 years for a population. They provide certain universal services for all children and young people as set out in the Healthy Child Programme working with their own team and others including health visitors, general practitioners and schools. Universal Plus Level School nurses are a key part of ensuring children, young people and families get extra help and support when they need it. They offer early help (for example through care packages for children with additional health needs, for emotional and mental health problems and sexual health advice) through providing care and/or by referral or signposting to other services. Early help can prevent problems developing or worsening. Universal Partnership Plus Level School nurses are part of a multi-agency approach to providing ongoing additional services for vulnerable children, young people and families requiring longer term support for a range of special needs such as disadvantaged children, young people and families or those with a disability, those with mental health or substance misuse problems and risk taking behaviours. School nursing services also form part of the high intensity multi-agency services for children, young people and families where there are child protection or safeguarding concerns.

4 Generic School Nursing Pathway 2.3 School Nursing in Medway The provider of the Medway school nursing service is Medway NHS Foundation Trust. The service is split into 2 teams; the Rainham and Gillingham team and the Chatham, Rochester and Strood team.

5 Medway Child Population Medway figures taken from 2011 Population Census Age 5-9 (Number/Percentage of Population) Age (Number/Percentage of Population) Age (Number/Percentage of Population) Total (Age 5-19) 15, % 16, % 19, % 51,763 21% Compared to England, Medway has a larger proportion of population between the ages of 0 and 14 years (18.9% compared to 17.7%) and between the ages of 15 and 24 years (14.5% compared to 13.1%). The largest numbers of children and young adults live in Chatham Central, Gillingham North, Gillingham South, Luton and Wayfield, and Strood South wards, with one fifth of their populations under the age of 15 years At the end of 2011 there were 449 Children in Care (CIC) of Medway Council. This represents 73 per 10,000 of the 0 18 year olds in Medway, which is higher than the national average of 59 per 10,000. Ratio of School Nurses to Pupils in Medway Team Chatham, Rochester & Strood Rainham & Gillingham Special Schools Team Total School Aged Population Number of Schools 24,172 Primary: 28 Senior: 8 Independent: 6 14,349 Primary: 54 Senior: 11 Independent/Altern ative Placement: SLD: 2 MLD: 1 Ave Caseload per school nurse 19 schools (6500 school aged children) 12 schools (4,000 school aged children) 240 school aged children Team Structure Team Leader 1 School Nurses 3 Staff Nurses - 4 Team Leader 1 School Nurses 3 Staff Nurses - 1 Team Leader 1 School Nurses 3 Key universal/core functions: health assessment at school entry, including the National Child Measurement Programme. Signposting of the family to and encourage the uptake of screening and/or services as a result Puberty sessions to Year 6/7 Make use of opportunities to promote healthy weight, sexual health services and emotional health and well-being services Offer support to schools in the delivery of the PHSE curriculum. (Note: a pilot project is currently underway to set a local curriculum and to train schools and teachers. School nurses will not deliver the whole programme, rather support schools/teachers to deliver the programme in each school, through training, running specialist sessions, providing resources).

6 Key targeted functions: identify and assess individual needs and develop an appropriate package of care/individual health plan, which may include referral to other services targeted intervention for emotional health and well-being Advise on and offer support for risk taking behaviours eg smoking, drug taking healthy weight sessions enuresis clinics Specific targeted functions: contribute as appropriate to the CAF, CHIN and CP processes work with the Looked After Children team, safeguarding team to support children and young people assessed as being vulnerable or at risk 2.4 Outcomes The school nursing service contributes to several public health framework outcomes and is measured against those outcomes. The specific Key Performance Indicators (KPI s) currently agreed for the service in Medway are detailed at Appendix 1. Domain 1 Improving the wider determinants of health Objective improvement against wider factors that affect health and wellbeing and health inequalities o Transition into Primary School number of Year R assessments undertaken as a percentage of the whole percentage of those that met criteria for satisfactory HAI (Note: for the purposes of the contract, the definition of satisfactory HAI at Year R is a child who assessment does not does not identify the requirement for further input at Universal Plus or Universal Partnership Plus levels) o Pupil absence where there is a known identified health need - within the Annual Report, how has School Nursing Service contributed to trying to achieve a reduction year on year o Enuresis clinics number of first and follow ups, number of children achieving continence as a percentage of the number of children on enuresis caseload Domain 2 Health improvement Objective People are helped to live healthy lifestyles, make healthy choices and reduce health inequalities o Under 18 conceptions in Annual Report, how has the School Nursing Service contributed to reduction in Under 18 conceptions year on year no of RSE sessions as a baseline o Excess weight in 4-5 yr olds no of children with a recorded weight as a percentage of the whole percentage that are not of a healthy weight o Self reported well-being in Annual report, results of well-being surveys to inform following year s service plan

7 o Smoking prevalence 15 yr olds number of stop smoking referrals to Medway Stop Smoking services Domain 3 Health protection Objective The population s health is protected from major incidents and other threats, while reducing health inequalities o Chlamydia diagnoses (15-24) for SNS yr olds number of signposting opportunities o SPA number of Single Point of Access referrals o Strategy meeting number of children on SNS caseload requiring a strategy meeting o CAFs Number of CAFs initiated by SNS service number of children requiring CAF with SNS involvement number of children with CAFs stepped up as a percentage of above number of children with CAFs successfully closed as a percentage of above o Safeguarding number of children requiring CHIN(Child in Need) with SNS involvement number of children requiring CP (Child Protection) with SNS involvement number of cases successfully closed as a percentage of the above 2.5 Exclusions to the Service Community nursing service to children in school with learning difficulties. This activity is commissioned by Medway Clinical Commissioning Group. Note: Public health school nursing activities for children with learning difficulties are commissioned by Medway Council). Year 6 (National Child Measurement Programme) this is undertaken by the Medway Health Improvement team Immunisation programmes and screening programmes commissioned by the NHS Commissioning Board are excluded from the service commissioned by Medway Council The healthcare needs of the residential (custodial) youth offending population are the commissioning responsibility of the NHS Commissioning Board and are therefore excluded from this service. Young people in further education colleges and in the first year of university receive public health and health promotion input from the health improvement team. The school nursing service liaises with and supports this function as required

8 2.6 Planned Developments The commissioning intention over the coming year is to work closely with the Provider to develop the service, better capture data so that there is a more indepth understanding of what the service can achieve. Specifically, the service is now working towards achieving You re Welcome accreditation. In addition, the service is participating with public health on the development and implementation of the Change4Life family support kit. KPIs are reviewed and agreed on an annual basis with the Provider. Planned developments this year have focussed on establishing a robust dataset. Next year s KPIs can be developed to focus on the proposed joint Health and Wellbeing Strategy themes for 2014/15 of: increased targeting of disadvantaged groups for promotion of healthy lifestyles, increased awareness of mental health conditions and support for prevention, early diagnosis and treatment amongst school aged children and contributing to a reduction in death rates from cardiovascular disease eg smoking cessation, harm reduction etc. Future plans for the re-tendering of the service are being discussed with category management. 5. Risk management Risk Description Action to avoid or mitigate risk Performance Historically this service was Collection of data monitoring commissioned as part of the block Development of contract between Medway PCT and service medway Foundation Trust. As a consequence, the service had never performance review had a service specification, had KPIs meetings or been performance managed by the commissioner. This meant that it was virtually impossible to quantify the contribution the schools nursing service made to the improvement of the health of and reducing health inequalities for children aged As a result of the schools nursing service being commissioned by Medway Council from April 2013, a service specification, KPIs and performance managing process were agreed with the service and put in place. Risk rating D2

9 Commissioning partners HCP (0-5) becomes the commissioning responsibility of MC in Oct 2015 School nurse post for Chatham has been difficult to recruit to The school nursing team is also commissioned by Medway CCG to provide community nursing to the special schools within Medway and by NHS England to provide an immunisation programme for school aged children. A full understanding of the commissioning synergies and links is needed in order to inform any future commissioning intentions. Need to forward plan for transition as particular synergies between the services Advert has been placed 3 times in recent months for a qualified school nurse for the Rochester/Chatham/Strood team. The adverts have had no responses to date. Effective and frank inter-agency commissioner discussions and relationships. Public health MC is a member of the transition Board for HV and co-chairs the FNP Advisory Board If there are no responses to the latest advert, the service will review the team structure and propose an interim team structure until Sept 14 when a new cohort of school nurses will qualify from university and a new advert can be placed A2 C2 A2 6. Implications for Looked After Children At the end of 2011 there were 449 Children in Care (CIC) of Medway Council. This represents 73 per 10,000 of the 0 18 year olds in Medway, which is higher than the national average of 59 per 10,000. Provision for looked after children is included in the schools nursing service and the service liaises specifically with the LAC team. Looked after children often have a greater degree of need of services at the levels of universal plus and universal partnership plus. It would be useful to incorporate some data collection for this group of the population in the next contractual year. 7. Financial and legal implications There are no financial and legal implications. 8. Recommendation Members are asked to note the report.

10 Lead officer contact Dawn Hollis, Senior Public Health Manager Commissioning and Assurance. Public Health Directorate, Level 2, Gun Wharf Tel: Background papers The public health outcomes framework for England, (2012) Dept of Health Getting it right for children, young people and families. (2012) Dept of Health

11 Appendix 1 School Nursing Service KPIs SECTION B PART 8 - QUALITY Section B Part 8.1: Quality Requirements No Performance Indicator Francis Report Internal Action Plan in relation to SNS Indicator Threshold Method of Measurement Number of Action number Plan to be Points reviewed quarterly Consequence of Breach COMMUNITY UNIVERSAL SERVICES 1 Each year, every school within Medway is allocated a named school nurse and is informed of the name and how to contact the service 2 Each GP practice in Medway has the contact details of the school nurse service and allocated schools 3 Key stage 4 clients are satisfied with the level of and quality of service provided by SNS 4 Key stage 4 clients are satisfied with the level of and quality of service provided 5 Children in Year R receive a HAI Number of schools within Medway that are allocated a named school nurse and are informed of the name and how to contact the service, as a percentage of the whole Number of GP practices within Medway provided with the SNS allocated schools list Percentage of clients surveyed who are satisfied with the level of and quality of service provided (minimal sample size 200) Indicative sample of complaints expressed as a percentage of the whole where parental consent is given that receive an HAI 100% List to be provided to the Commissioner by 31 st July each year and quarterly if revisions occur 100% List to be provided to the Commissioner by 31 st July each year and quarterly if revisions occur >94% Client feedback forms 2 (number) 95%

12 UNIVERSAL PLUS 6 Children in Year R receive an HAI 7 Children in Year R achieve a satisfactory HAI 8 Children aged 4-5 yrs are of a healthy weight 9 Children aged 4-5 yrs are of a healthy weight 10 Children aged 4-5 yrs are of a healthy weight 11 Children aged 4-5 yrs are of a healthy weight 12 Children aged 15 who smoke choose to stop smoking 13 Children/YP with an identified medical need, who are known to the service have an individual health plan (in partnership with the school) expressed as a percentage of No 5 where parental consent is not obtained expressed as a percentage of No 5 that meet the satisfactory criteria Number of 4-5 yr olds with a recorded weight as a percentage of all 4-5 yr olds on caseload who are of a healthy weight, expressed as a percentage of No 8, also expressed as a percentage identified as having an overweight or very overweight centile that are referred to the Medway Supporting Healthy Weight Team (MSHWT) Number of Children, also expressed as a percentage, whose parent/guardian has opted out of being referred and why Number of 15 year olds who are referred to a stop smoking programme Number of children/yp with an identified medical need, who are known to the service that have an individual health plan, expressed as a percentage of the whole 0% 80% Baseline to be verified in year above coverage rates of 2011/12 (91.3% of all eligible) Baseline to be verified in year Number/percentage Number/percentage Number Baseline in year

13 UNIVERSAL PARTNERSHIP PLUS 14 Children who are on the enuresis clinic caseload achieve continence (excludes those children whose medical condition precludes achievement of continence) 15 Children have a positive sense of wellbeing and mental health 16 Children have a positive sense of wellbeing and mental health 17 Children have a positive sense of wellbeing and mental health 18 Children have a positive sense of wellbeing and mental health 19 Children have a positive sense of wellbeing and mental health 20 Children who are at risk of harm are identified and a plan of care is in place 21 Children who are at risk of harm are identified and a plan of care is in place 22 Children who are at risk of harm are identified and a plan of care is in place 23 Children who are at risk of harm are who achieve continence as a percentage of the number of children on enuresis clinic caseload referred to Single Point of Access (SPA) on SNS caseload requiring a strategy meeting where a CAF for health reasons is initiated and there is input from the SNS with CAFs stepped up as a percentage of No 17 with CAFs successfully closed as a percentage of No 17 requiring CHIN with SNS involvement requiring CP with SNS involvement Number of CHINs successfully closed as a percentage of No 20 Number of CPs successfully closed as a percentage of Baseline to be verified in year Number Number Number Number/percentage Number/percentage Number Number Number/percentage Number/percentage

14 identified and a plan of care is in place 24 Children who are at risk of harm are identified and a plan of care is in place No 22 Number of reports not submitted at least 5 days before meeting and reason, expressed as a percentage of the total number of reports submitted (Include IPCP and RPCP) Number with reason Notes: For this specification, definition of satisfactory HAI at Year R is a child who does not require further input at Universal Plus or Universal Partnership Plus levels Age 4/5 weight height and weight correlate on percentile charts Weight Definitions: o Underweight - below 2 nd BMI centile o Healthy weight - between 2 nd and 90 th BMI centile o Overweight - Between 91 st up to 97 th BMI centile o Very Overweight - At or above 98 th BMI centile Survey tools used to be mutually agreed by Commissioner and Provider. Annual Report: The annual Report is to be submitted to the Commissioner yearly by 1 st September, reflecting an academic year. The annual report must Demonstrate how the service has contributed to the national school nursing service outcomes (see Section 4) o Healthy weight data analyse the healthy weight data identified above and propose developments to service as a result o Comment on number of stop smoking referrals for 15 yr olds compared to the local stop smoking picture Demonstrate how the service has contributed to improving health outcomes at the level of the Community Offer Include outcome of surveys, action plan and changes to service made as a result of results As part of a Francis Review o Include analysis of complaints made of the service during the year and action plan o Analysis of staffing levels and vacancies, impact on service etc Participate in meetings to review dash board, analyse results, review service plan (Initial monthly meetings for 6 months)

15 Section B Part 8.2: Nationally Specified Events NA Section B Part 8.3: Never Events Never Events Threshold Method of Measurement Never Event Consequence (per occurrence) Misidentification of Patients >0 Review of reports submitted to National Patient Safety Agency (or successor body)/serious Incidents reports and monthly Service Quality Performance Report In accordance with applicable Guidance, recovery of the cost of the procedure and no charge to Commissioner for any corrective procedure or care Section B Part 8.4: 18 Weeks Referral-to-Treatment Standard for Consultant-led Services Financial Adjustments Table Not Applicable Section B Part 8.5: Clostridium difficile Adjustments Tables Not Applicable SECTION B PART 9 - QUALITY INCENTIVE SCHEMES Section B Part 9.1: Nationally Mandated Incentive Schemes None Section B Part 9.2: Commissioning for Quality and Innovation (CQUIN) Not applicable Section B Part 9.3: Locally Agreed Incentive Schemes None SECTION B PART 10 - ELIMINATING MIXED SEX ACCOMMODATION PLAN NA

16 SECTION B PART 11 - SERVICE DEVELOPMENT AND IMPROVEMENT PLAN Service Development and Improvement Plan Description of Scheme Development of CAF pathway in conjunction with Medway Council Review to establish whether regular meetings to discuss vulnerable children and young people with GP practices can be rolled out to other surgeries.. Monitoring and development of KPIs and data recorded Assessment of readiness and plan for achieving You re Welcome accreditation Participation in the development and implementation of the Change4Life Family Support Kit (inc attendance at working group) Milestones Timescales Expected Benefit Revised CAF pathway Practices within each locality engage in regular meetings with the SNS A defined data set that demonstrates the activity and outcomes of the SNS You re Welcome Accreditation Launch of the Change4Life Family Support Kit Evaluation report of the Change4Life Family Support Kit March 2014 March 2014 March 2014 Sept 2014 March 1014 Earlier input from SNS into CAFs for children with health/schooling needs Improved communication between agencies leading to improved support and outcomes for children Improved quality of data and evidence effectiveness of service Improved quality of service for young people Improved quality of service for young people Consequence of Achievement/ Breach

17 SECTION B PART 12 - SERVICE USER, CARER AND STAFF SURVEYS Annual user and carer surveys. Survey tool used to be mutually agreed by Commissioner and Provider. Outcome of surveys, action plan and changes to service to be included in annual report. SECTION B PART 13 - CLINICAL NETWORKS AND SCREENING PROGRAMMES See Section 6 SECTION B PART 14 REPORTING AND INFORMATION MANAGEMENT Section B Part 14.1: National Requirements Reported Centrally NCMP Section B Part 14.2: National Requirements Reported Locally None

18 Section B Part 14.3: Local Requirements Reported Locally Monthly report Key Strategic actions being undertaken The service will report monthly on the following data per locality: (collected via NMAS or other database) Clinics (list by clinic type) first and follow ups, DNAs Parental face to face contact (meeting or ad-hoc) Telephone contacts (with parent or child or HCP, or education, or social care) Number of YR assessments completed, known to the service who need a health plan (caseload), known to the service who have a health plan Number of new health plans initiated CAF Caseload total number, new, closed CAFs first case conferences attended CAFs number of meetings attended and for the number of children CHINs total number, new, closed CPs total number, new, closed CPs number of conferences attended and for number of children CPs number of reports not submitted at least 5 days before meeting and reason (Include IPCP and RPCP) PSE sessions at schools attended No of awareness sessions eg asthma, anaphalyxis Registers of allergic children asthma, eczema, anaphalyxis Registers of children with illnesses diabetes, epilepsy, List of public health school nursing activities provided for children in special schools Section B Part 14.4: Data Quality Improvement Plan Data Quality Indicator Data Quality Threshold Method of Measurement Milestone Date Consequence