Children s Trust Board Sponsor: Dr Kate Allen, Consultant in Public Health

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1 Report to Children s Trust Board 6 th November 2014 Agenda Item: 4 Children s Trust Board Sponsor: Dr Kate Allen, Consultant in Public Health NOTTINGHAMSHIRE SCHOOL NURSING SERVICE REVIEW IMPLICATIONS FOR COMMISSIONERS Purpose of the Report 1. To share key findings of the Nottinghamshire School Nursing Service review To seek approval of the proposed remodelling of the School Nursing Service prior to presentation at the Public Health Committee on 28 th November Information and Advice Current Commissioning of the School Nursing Service 3. The responsibility for commissioning School Nursing transferred from Primary Care Trusts (PCTs) to Public Health in the Local Authority in April 2013, following the Health and Social Care Act Public Health within Nottinghamshire County Council is responsible for commissioning the service to cover all of Nottinghamshire including Bassetlaw. 4. The School Nursing Service in Nottinghamshire is also commissioned to lead on a statutory duty for the Local Authority to deliver the National Child Measurement Programme (NCMP). There is currently a separate service specification for the NCMP however it is envisaged that this will be included in the main school nursing specification from As an interim measure the performance management of NCMP is now included within the main performance management of the School Nursing Service. Review Methodology 5. A service review was undertaken to gain evidence to shape the commissioning of Public Health School Nursing Services from 2016/17 and beyond. 6. The review began in 2012 and was led by public health. A summary of the methodology is as follows: Steering group established including representations from Public Health Nottinghamshire and Health Partnerships. 1

2 Family of School profiles developed and made available on Nottinghamshire County Council website Survey for Head Teachers, Teachers and School Governors responses Survey for Stakeholders (including GP s, Local Authority services, Voluntary and Community Sector, Health services) responses Survey for School Nurses - 62 responses Workshops with School Nurses - 78 participants Survey for young people 1,609 responses Workshop for young people 12 participants Detailed analysis of findings is available to download from Current provision across Nottinghamshire 7. As identified by the provider of services the aim of the School Nursing Service is to enable each school child to attain his/her optimum health and educational potential. The service is a partnership with the child/young person, parent/carer and education Current provision is delivered by the Locality Child Health Teams of Health Partnerships within Nottinghamshire Healthcare Trust. These teams lead on the delivery of the Healthy Child Programme 0-19 years and include Health Visitors (0-5 years) and School Nurses (5-19 years). Health Visiting is currently commissioned by NHS England and will transfer to the Local Authority in October The service aligns its six Child Health Teams with Clinical Commissioning Group (CCG) boundaries. 10. The service is made up of a range of staff roles including qualified Public Health Nurses (Senior School Nurses), Health Care Assistants, Community Nurses, Community Health Advisors for young people, Community Health Assistant Practitioners (formerly nursery nurses), Community Support Workers, and clerical support staff. There are only 3.7 WTE Senior School Nurses across Nottinghamshire. 11. There are currently WTE School Nurse roles across Nottinghamshire and there are 341 schools. This results in 0.28 WTE School Nurses per school. In addition nurses in Newark and Sherwood, Mansfield and Ashfield also deliver special school nursing so there is a greater reduction in the Public Health Nursing functions in these districts. 12. Commissioners have been aware for some time that there is patchy school nursing provision across Nottinghamshire, which is not necessarily based on where needs are greatest. In addition, it is also acknowledged that schools have 1 CHP (2014) Nottinghamshire Services for Schools Brochure

3 a mixed view of the service, and schools have requested consistency of provision so they understand what they can expect from the service. 13. There is inconsistent delivery of current activity across Districts and CCG areas. This is partly historic stemming from locality based Primary Care Trusts who commissioned services very differently. For example school nurses in Rushcliffe offer clinic in a box within most of the secondary schools in the area, this intervention includes pregnancy testing and emergency hormonal contraception. However this is not offered in Mansfield where teenage conception rates are highest. Bassetlaw has a separate vaccination and immunisation team so that the school nurses do not offer this service; likewise the Bassetlaw provider of Contraception and Sexual Health (CaSH) services offer outreach clinics in all secondary schools which means that the School Nurse is not required to offer contraception interventions including pregnancy testing. 14. It is recognised that the current School Nursing Service has displayed some excellent practice in many areas and yet this is not often communicated to wider partners or within the service itself. 15. There is a separate Children in Care nursing team which covers Nottinghamshire including Bassetlaw. In addition there is one dedicated specialist nurse practitioner attached to the Youth Offending Team which covers all of Nottinghamshire. These services are also provided by Nottinghamshire Healthcare Trust, and are the commissioning responsibility of CCGs. Key Findings 16. A summary of key findings include the following: a) Young people think School Nurses are caring, trustworthy and knowledgeable b) The School Nursing Service is valued by schools and stakeholders c) Despite positive feedback, 18% of schools stated that the current service was poor or very poor. d) School nursing activity varies across Nottinghamshire CCG areas. e) Young people and schools are unclear who their School Nurse is and how to contact them f) Schools, stakeholders and young people would like a clearer understanding of what they can expect from school nurses. g) School nurses would value a standard operating framework to guide their work and ensure that they have clear pathways in place and a clear model of what is expected of their role. h) Schools and stakeholders are concerned about the lack of consistency across the service, the increasing demands of safeguarding, as well as the apparent reduction in availability of school nurses in the last few years, 3

4 i) School nurses face a number of demands on their time including child protection, which means that key public health roles such as health promotion are not prioritised. j) Schools believe that there are a number of essential advice roles that the service should offer, specifically advice and interventions focussing on sexual health and sexually transmitted infections, contraception, eating disorders, healthy weighty and weight management, depression, pregnancy, anxiety, drugs, smoking cessation and alcohol, in particular in secondary schools. k) Young people identified that there are a number of interventions that they would like to see the School Nurse provide in the future. Information from the workshop and questionnaires identified that young people want the School Nursing Service to offer the following: Sexual health and relationships support including, contraception and pregnancy testing, advice on pregnancy, advice on sex and relationships, sexuality and the C-Card scheme. Emotional health and well-being including, eating disorder support, feeling down, stress and anxiety, self-harm, how to access counselling and advice on bullying. Advice on drugs, alcohol and stopping smoking. Regular health checks including height, weight, vision and hearing. Support with family issues. A variety of interventions with young people including one to one appointments, drop in services, as well as input into PSHE lessons, school assemblies and events such as health days. l) School nurses want to carry out more targeted outreach work with children and young people most in need. m) School nurses would like to contribute to PSHE programmes and health promotion campaigns to support children and young people. n) Schools do not think that the School Nursing Service should provide first aid support, providing medication or vaccinations or jabs, as these are or should be provided elsewhere e.g. school first aider and GP practice. There may however be a training need for schools following impending new statutory guidance Supporting pupils at school with medical conditions 2 o) Schools and young people would like to see a School Nurse based in school all of the time. p) Current performance and data collection does not provide evidence of how outcomes are improved. 2 DfE (2014) Supporting pupils at school with medical conditions. Statutory guidance for governing bodies of maintained schools and proprietors of academies in England (DRAFT) https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/277025/draft_statutory_guidance_o n_supporting_pupils_at_school_with_medical_conditions_for_consultation.pdf 4

5 q) There is low morale within the service, with a perceived lack of investment in comparison to the national focus on Health Visiting. r) School Nurses would like to carry out more targeted work with children and young people most in need. They did however state that to achieve this they would need to have improved data sharing with others to identify those with additional needs or those educated at home for example. Summary of Commissioning Recommendations following the review 17. Accessibility, visibility and communications Commissioners will want to see improved promotional activities with children, young people and families, schools and wider stakeholders about the role of the School Nursing Service. Commissioners will need to also include within tender documentation the development of social media methods to engage young people. 18. Defined role and function Commissioners will require the development a standard operating framework for the service, to guide work and ensure clear pathways are in place with a clear model for service delivery. 19. Consistency Commissioners will require consistency of provision across all localities across Nottinghamshire. This in turn also requires that teams have the right skills to do their job. It may also be useful to shape the teams based on the three localities of Nottinghamshire rather than basing teams on CCG boundaries. 20. Targeted There will be a requirement for additional outreach work with children and young people not in mainstream school including those being educated at home, those in Pupil Referral Units and alternative education; as well as those without a school place and year olds in need. Key localities will need to be targeted for some interventions e.g. offering sexual health and contraception provision in teenage pregnancy hot spot wards. 21. Prioritisation Delivery of public health priorities and evidence based interventions is required. The School Nursing Service need to cease work that is not included within the service specification e.g. incontinence and enuresis clinics. 22. Health promotion - Deliver to key public health priorities, including emotional health and wellbeing, smoking prevention, healthy weight, and improved sexual health. This will result in some elements of work (with no evidence base) ceasing to increase capacity e.g. hearing and vision screening. 23. Reporting - Improved use of performance management systems across the service to collect evidence of activity and impact; as well as routine feedback from service users, schools and stakeholders. Conclusions from the Review 24. The School Nursing Service is a valuable service which aims to improve the health and well-being of children and young people in Nottinghamshire. The service is valued by schools and stakeholders. However further work is required to strengthen its role and promote the interventions offered. 5

6 25. Commissioners would also like to understand if the service offers value for money and how the service operates to improve capacity e.g. recruitment to vacant posts, relocation of staff to meet needs as well as a budget breakdown. Without concrete evidence of this it will be a challenge for commissioners to identify if the service provides value for money alongside positive interventions which improve outcomes for children and young people. 26. Commissioners require improved reporting that not only monitors numbers seen, but captures activity data as well as evidence of how key health outcomes have been improved. The active engagement of service users and stakeholders is a clear recommendation. Commissioners will also want to be reassured that there are workforce plans that include training, retention and forward planning for recruitment as appropriate. 27. It would be useful to engage schools and key stakeholders such as Targeted Youth Support in plans to remodel the service. Remodelling the service 28. The new service specification will include the following changes to the service: a. The service name will change so that all involved understand the broader role of the school nurse in non-school settings, e.g. public health nurse 5-19 year olds. b. Public Health within Nottinghamshire County Council will be commissioning a Public Health Nursing service for 5-19 year olds and so an additional focus on public health outcomes will be a necessity. To achieve this, the service will need to increase its health promotion role which is fully supported by school nurses, and some work will need to cease. c. There will be a reduction in some provision and an increase in other interventions. Schools for example will need to understand the reduction of some interventions, especially primary schools that rely on the School Nurse to offer lessons on hand washing, brushing your teeth etc. These elements of work should be provided by school staff. However it is accepted that secondary schools will require additional support to engage young people in key priority health messages re healthy relationships, resilience, and early intervention for risk taking behaviours. d. Involvement in child protection panels will only be required for 5-19 year olds where a health issue has been identified that the School Nurse can address. e. Vision and hearing screening and incontinence services will not be commissioned through public health in the Local Authority. f. It is understood that there will be a separate vaccination and immunisation service commissioned by NHS England to deliver the national school age vaccination programmes. g. There will be increased health promotion interventions for 5-19 year olds with particular focus on secondary schools. h. The service will be commissioned to offer a drop in session in or near each secondary school across Nottinghamshire. 6

7 i. There will be greater integration with Health Visiting to aid the transition between services. j. There will be a requirement to work with target groups including young offenders; those educated at home, those excluded from schools, Children in Care, etc. Health Partnerships already provide the Children in Care team and the nurse working at the Youth Offending team, closer working between these services is also required. k. There will be a requirement to ensure that the service is needs led, having consistent services across Nottinghamshire with additional targeted interventions where those interventions are needed most. l. The service will be based on the three localities used by the Local Authority rather than CCG boundaries. m. There will be a standard operating framework for the service. n. There will be improved promotional work led by the service to ensure that stakeholders, children, young people and families understand who to contact and what support is available. o. There will be a requirement for partnership working with the Early Help Unit. p. The NCMP will be integrated into commissioning plans for the Healthy Child Programme. Next Steps for Commissioners 29. Share findings with key groups including Schools, Governors, and additional stakeholders e.g. those working with target groups. 30. Commissioners plan to procure an integrated service to deliver the Healthy Child Programme. The commissioning of School Nursing, Health Visiting and Family Nurse Partnership may be combined with commissioning of Children Centres if timescales allow. 31. Commissioners are due to begin a tender process in the next year to enable a service with a new service specification to be in place in Findings of this review will help the development of the tender specifications and external interested parties will also be able to access this report through the Nottinghamshire County Council website. In the meantime, there will be continued engagement with the existing provider of public health nursing services to evidence impact and share the findings of this review. 32. Serve notice on the current provider with a procurement exercise taking place to establish a new service to be in place in Involve a number of representatives in shaping the tender documentation and procurement panels including schools, young people and public health. 7

8 RECOMMENDATION/S 1) The Children s Trust Board notes the content of the report. 2) The Children s Trust Board approves the proposed changes to how the future service is remodelled. 3) The Children s Trust Board agrees with the proposed next steps for commissioning and the need to procure am integrated Healthy Child Programme Irene Kakoullis Senior Commissioning and Public Health Manager For any enquiries about this report please contact: Irene Kakoullis Background Papers Except for previously published documents, which will be available elsewhere, the documents listed here will be available for inspection in accordance with Section 100D of the Local Government Act 1972 Nottinghamshire School Nursing Review, September 2014 implications for commissioners (including Appendices 1-3) available at Healthy Child Programme and Public Health Nursing for children and young people, Children s Trust Board 6 th March 2014 Healthy Child Programme and Public Health Nursing for children and young people, Nottinghamshire Health and Wellbeing Board, 8th January

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