School Nurse Provision in Lincolnshire

School Nurse Provision in Lincolnshire A REVIEW BY THE HEALTH SCRUTINY COMMITTEE FOR LINCOLNSHIRE October 2008

HEALTH SCRUTINY COMMITTEE FOR LINCOLNSHIRE SCHOOL NURSE PROVISION IN LINCOLNSHIRE 1. INTRODUCTION 1.1 The Health Scrutiny Committee for Lincolnshire has undertaken a light-touch review of school nurse provision in Lincolnshire. Councillors Mrs A Puttick, Miss J Frost and Mrs P Watson formed a task group to undertake this review on behalf of the Committee. Terms of Reference 1.2 The approved terms of reference for the review were as follows: - To identify the extent of the existing school nurse provision in Lincolnshire. 1.3 The review specifically excluded the health visitor service and the services provided at Children s Centres. The focus of the review was the school nursing service provided in Lincolnshire s maintained schools. Methodology 1.4 The review has involved meetings with the relevant managers at NHS Lincolnshire and there has been one meeting with a representative group of school nurses. The Committee is grateful to all those who supported the review. The Committee issued a questionnaire to all maintained schools in Lincolnshire and is grateful to the 220 Lincolnshire schools, who completed this questionnaire. 2. POLICIES ON SCHOOL NURSING National Policies 2.1 In February 2005, the Government published Choosing Health Making Healthy Choices Easier. This White Paper stated that by 2010 each primary care trust would be funded to provide at least one full time, year-round qualified school nurse working with each cluster or a group or primary schools and the related secondary school, taking account of health needs and school populations. Applying this to Lincolnshire would mean an establishment of 63 school nurses (based on the existing number of secondary schools July 2008 figures). However, we understand that the East Midlands Strategic Health Authority has advised that 0.5 qualified school nurse per secondary school and feeder primary school cluster has been used as the standard. The school nursing figures are detailed in paragraph 3.1 below. The number of qualified school nurses in Lincolnshire means that there is currently a shortfall against both national and regional standards. 1

2.2 High Quality Care for All was published by the Department of Health, in June 2008 and outlines the outcomes of the Lord Darzi review of the National Health Service. High Quality Care for All includes a section outlining the work of regional working groups on eight pathways of care, which were co-ordinated by regional health authorities. High Quality Care for All makes the following statement in relation to the children s pathway of care, which supports the continuation and development of the school nursing service: It was felt that services need to be more effectively designed around the needs of children and families, delivered not just in health settings but also in schools and children s centres. 1 2.3 High Quality Care for All also refers to the publication in the autumn of 2008 of the Child and Young People s Health Strategy. This strategy will seek to build on the new Child Health Promotion Programme that sees highly skilled health visitors and school nurses supporting families on health and parenting from pregnancy onwards. 2 Local Policies 2.4 The County s Children and Young People s Plan 2007-2012 acknowledged that inequalities existed in some geographical areas in terms of access to school nursing. The Plan included a commitment to develop solutions for difficult-tofill vacancies such as school nursing. 2.5 From Evidence to Excellence Our Clinical Vision for Patient Care 3 sets out the East Midlands Strategic Health Authority s findings and proposals on the eight Lord Darzi workstreams. On the children s health workstream, the Strategic Health Authority cites a lack of capacity amongst school nurses leading to poorer outcomes for children as an example of a challenge across the region. NHS Lincolnshire, together with all primary care trusts in England, will be preparing a three-five year commissioning strategy by December 2008. It is understood that NHS Lincolnshire s commissioning strategy will build on the NHS Lincolnshire s previous Shaping Health outcomes, which set out the high level vision for health care in Lincolnshire. 2.6 The Health Scrutiny Committee is in a position to examine the extent to which NHS Lincolnshire s three to five year commissioning strategy will adequately reflect the need for appropriate school nursing provision in Lincolnshire. 3. CURRENT PROVISION IN LINCOLNSHIRE Number of School Nurses 3.1 We were advised that as of April 2008, the establishment for school nurses stood at 35.87 full time equivalents. The number of pupils on roll at all schools 1 Page 18, High Quality Care for All (Department of Health June 2008) 2 Page 34, High Quality Care for All (Department of Health June 2008) 3 East Midlands Strategic Health Authority, June 2008 2

in Lincolnshire for the summer term 2008 totalled 102,835 pupils. On this basis there is one school nurse per 2,867 pupils. However, if nursery school and 16 plus pupils (totalling 9,254) are excluded, there is one school nurse per 2,609 pupils. We were told in April that nine nurses had the specific school nurse qualification (see paragraph 3.5 below), with the remainder qualified as either a registered nurse or a health care assistant. Three newly qualified nurses were due to complete their training during March / April 2008 and during September 2008 there will be a further recruitment round, seeking up to eight additional school nurses. We commend the efforts of NHS Lincolnshire in continuing to increase the number of school nurses. 3.2 We understand that most school nurses are employed during term time only. The Government advises that school nurses should be employed for the full year. We understand that NHS Lincolnshire is aiming for at least one full time nurse in each team. Recruitment and Training 3.4 To become a qualified school nurse, one has to be a registered nurse with experience working with children and then undergo training (usually undertaken as block release) for one year. The qualification is in Specialist Community Public Health Nursing. Historically, many nurses working in Lincolnshire do not have this qualification. However, many nurses have experience working in schools and with children. A further issue is that the age profile of the existing workforce means that a significant number of nurses will be due to retire in the next few years. 3.5 The entry requirements to the school nursing profession mean that it is likely that there is no ready supply of school nurses in Lincolnshire. We understand that a varied approach will be used to recruiting nurses, such as seeking candidates from outside the county, developing existing nursing assistant staff and increasing existing staff hours (for example, from part time to full time). However, we recognise that recruitment and retention present a major challenge for NHS Lincolnshire. Budget for School Nursing 3.6 The focus of our review has been on the service provided in schools, rather than the budgetary provision. However, we were advised that approximately 1.5 million is currently spent by NHS Lincolnshire on school nursing in the county. A fully qualified school nurse costs about 40,000 per annum. This includes a Band 6 nurse salary (up to 32,000 per annum) and 20% additional and non-pay costs. Partnership Working 3.7 NHS Lincolnshire is both the commissioner and provider of the school nursing service. There is, however, a division between the commissioner and provider roles at NHS Lincolnshire. The provider arm is managed by the Managing Director of Provider Services, who sits on the NHS Lincolnshire Board. The Assistant Director of Children s Services, Mental Health and Learning Disability 3

is the lead officer at NHS Lincolnshire for the commissioner role. Lincolnshire County Council s Director of Children s Services is the chairman of the Children and Young People s Strategic Partnership. This body retains an overview of all health services commissioned for children and whilst it has no executive responsibility, it can be influential in supporting the development of partnership working, and the transfer of budgets. 3.8 We understand that school nurses are going to be linked to the development of locality based teams in the county, enabling links with social services and other children s services staff. Core Offer 3.9 NHS Lincolnshire has developed a core offer for its health visiting and school nursing services. One aspect of this is a new job description and job title of community health practitioner for school nurses. We also believe that it also reflects the needs-based school nursing, which is sometimes referred to as the Lancaster model. The aim of needs-based nursing is to target school nursing resources, where there is most need. 3.10 The core offer will include the following elements: - Health needs assessment and obesity monitoring (Reception) Complex needs / learning disability / physical disability Managing medicines in schools Health needs assessment (Year 6) Puberty (Years 5 and 6) Obesity monitoring (Year 6) Tier 1 CAMHS School Nurse drop in sessions Health Needs Assessment (Year 10) Common Assessment Framework Child Protection 3.11 Overall there is much positive work by NHS Lincolnshire in both increasing the number of nurses and developing the service offered to schools. 4. SCHOOL QUESTIONNAIRE 4.1 A full summary is set out in Appendix B to this report. A full report, detailing all the responses, has also been prepared and is available separately and will be submitted to NHS Lincolnshire. 4.2 The headline findings from the questionnaire are as follows: - 53% of schools overall are not satisfied with the amount of school nurse time allocated to the school. 43% are satisfied and 4% have no opinion. There are significant variations in how often schools are visited. For example, most secondary schools are visited once per week, but many primary schools were only visited once per term on average. Some schools had not had contact with the service for some time. 4

75% of schools believe that the school nursing services is very important, while 24% of schools believe the service is important. The highest three priorities identified by the schools for the school nursing service are: health education and promotion; child protection and safeguarding; and advice on children with complex needs. Many schools were highly complimentary of their individual school nurse, but would like more time from the service. 4.3 The questionnaire results also identify other issues. For example, there are variations in the levels of satisfaction with the amount of time allocated in different parts of the county. This may reflect the needs-based model, which NHS Lincolnshire is developing, but could also reflect historical differences in provision. 4.4 There are also particular needs with some of the special schools, which merit further attention and are considered in section 6 below. 5. LOCAL AREA AGREEMENT AND REDUCING CHILDHOOD OBESITY 5.1 The Improve Health Priority in the Lincolnshire Local Area Agreement includes two targets from the National Indicator Set, which relate to a reduction in obesity levels of children in Reception and Year 6. NHS Lincolnshire is identified as the lead partner for this activity and the core offer of school nurses refers to the assessment of children. 4 5.2 Weight and height assessments in Reception and Year 6 are undertaken in accordance with Department of Health and Department for Children, Family and Schools guidelines 5, which for the 2008/09 school year and future years will be underpinned by new regulations. We have been advised that where a child is absent from school on the day of measuring or where parents specifically opt out of the measuring, there is a requirement that the child is recorded as obese. We also understand that this is a national requirement and would apply to all local authorities. However, there is a concern that this might over-represent the number of obese children in Lincolnshire schools. 5.3 The importance of obtaining a reliable set of data is reinforced by a comment, which we received from one primary school in South Holland district: - There is no check on children s health, height, weight, etc. 6. SCHOOL NURSING IN SPECIAL SCHOOLS 6.1 We heard from school nurses that some school nurses feel under-qualified when working in special schools. We were told that Sheffield has specialist nurses. We also heard from one of our special schools that North East Lincolnshire has specialist school nurses for its special schools. 4 Page 15 of Big County Big Skies Big Future Help Us Shape Tomorrow s Lincolnshire Today Lincolnshire Local Area Agreement 2008-2011. 5 The National Child Measurement Programme Guidance for PCTs: 2008/09 School Year (Department of Health and Department for Children, Families and Schools, 4 August 2008) 5

7. ACCOMMODATION IN SCHOOLS 7.1 The Health Scrutiny Committee s review of the Healthy Schools programme (February 2008) made the following recommendation in relation to accommodation: - That provision planning for schools take account of the accommodation needs of health staff. 7.2 In our discussion with school nurses, we were told that it is often difficult in primary schools for nurses to see parents and pupils in a confidential setting. In secondary schools, accommodation provision varies depending on the priorities and available facilities of the school. The nurses we visited emphasised that confidentiality is important for any one-to-one meeting. 8. PUPILS IN OTHER SETTINGS 8.1 There are a number of pupils who at any one time may be outside a school setting. Such pupils may be home-educated; or awaiting a placement, for example, following an exclusion. There are also pupils outside the maintained sector. These represent challenges for the school nursing service as it develops over the next two years. 8.2 We received a response to our questionnaire from Solutions 4. Solutions 4 is technically a pupil referral unit, but operates on eleven sites across the county providing alternative education to pupils at Key Stage 4, who in most instances have been permanently excluded on at least one occasion. These sites can vary in size from six to 50 pupils and overall Solutions 4 provides education to approximately 250 pupils. Solutions 4 stated in its response to our questionnaire that it had not received any contact from the school nursing service since 2006-2007. As the pupils attending Solutions 4 are one of the most vulnerable groups in the county, we believe it is important for the school nursing service to offer services to these pupils. 9. CONCLUSION AND RECOMMENDATIONS 9.1 We are grateful to schools for responding to our questionnaire. It is absolutely clear from our analysis of the questionnaire responses that schools have a very high regard for the school nursing service. We in turn, as members of the Health Scrutiny Committee, put a similarly high value on this service. We would like to see the service develop and prosper with the full support of NHS Lincolnshire. We have seen evidence of NHS Lincolnshire s plans to develop the core offer to schools and at the same time to introduce the Lancaster needs-based model of school nursing. We are interested in how these are going to be implemented in practice in schools and look forward to progress reports on this at future meetings of the Committee. 9.2 We are pleased to note the efforts of NHS Lincolnshire to increase the number of school nurses and related staff, who work to support Lincolnshire schools. At the same time, we also recognise that entry to the school nursing profession 6

is restricted to candidates with certain prior qualifications and a commitment to further training, which makes the recruitment of staff into the service a challenge. However, this matter, together with financial considerations, should not be an obstruction to the continued development of the service and we urge NHS Lincolnshire to continue their efforts to increase the number of qualified school nurses, other nurses and nursing assistants working in schools. 9.3 There is a separate report entitled Survey of School Nurse Provision Detailed Report, which sets out in full the responses of all the schools, who participated in the survey. We commend this document to the relevant officers at NHS Lincolnshire, so that they can consider some of the detailed issues raised by schools. 9.4 We make the following recommendations. Recommendations 1. We note the efforts of NHS Lincolnshire during 2008/09 to add qualified school nurses to the workforce in Lincolnshire. We recommend that NHS Lincolnshire provide a commitment to yearon-year increases in the number of qualified school nurses, other registered nurses and nursing assistants, providing support to Lincolnshire schools, until the Government s target is reached. To this end we encourage NHS Lincolnshire to provide a statement in terms of the increase in staffing levels against the Government s target, over the next three years. 2. We have prepared a separate document, entitled: Survey of School Nurse Provision Detailed Report which details all the comments received from schools in relation to the school nursing service. We recommend that NHS Lincolnshire respond to the Committee on the following issues highlighted in this detailed report: - (a) (b) (c) the provision of information to schools on the services offered (the core offer) and the need to advise schools of the particular services, which are or are not part of the offer; the differing expectations of primary and secondary schools, in terms of priorities; and the particular requirements of special schools and pupil referral units, including Solutions 4. 3. We have prepared a separate document, entitled: Survey of School Nurse Provision Detailed Report which details all the comments received from schools in relation to the school nursing service. While there are a small number of negative comments in this document, the overwhelming message from schools is one of praise and compliments for school nurses and the services provided. We recommend that this positive message is passed on to all the school nursing staff. 7

4. We recommend that NHS Lincolnshire report on an annual basis to the Health Scrutiny Committee on the level of school nurse provision and future plans. HEALTH SCRUTINY COMMITTEE FOR LINCOLNSHIRE OCTOBER 2008 8

APPENDIX A LIST OF EVIDENCE 1. Report into Health Visiting and School Nursing Service Provided by NHS Lincolnshire (Ginny Blackoe, Associate Director of Children and Family Services, NHS Lincolnshire October 2007) 2. School Nurse: Practice Development Resource Pack (Department for Education and Skills and Department of Health March 2006) 3. Looking for a School Nurse Non-Statutory Guidance (Department for Education and Skills and Department of Health March 2006) 4. High Quality Care for All (Department of Health June 2008) 5. From Evidence to Excellence Our Clinical Vision for Patient Care (East Midlands Strategic Health Authority June 2008) 6. Results of Survey of Lincolnshire Schools (Health Scrutiny Committee for Lincolnshire August 2008) 7. Notes of Meetings Meeting with Ginny Blackoe, Associate Director of Children and Family Services, NHS Lincolnshire, 14 March 2008 Meeting with Allan Kitt, Assistant Director, Children s Services, Mental Health and Learning Disabilities, NHS Lincolnshire, 24 July 2008 Meeting with Paul Watson, Kathleen Davey and Diane Baker (School Nurses) 2 July 2008 9

APPENDIX B SUMMARY REPORT ON QUESTIONNAIRE ON SCHOOL NURSE PROVISION JUNE / JULY 2008 INTRODUCTION (i) A short questionnaire was sent to all Lincolnshire s maintained schools in June 2008. The response rate to the survey was high. 58% of primary 6 schools, 60% of secondary 7 schools and 62% of special schools responded. In addition, two of the five pupil referral units 8 responded. The purpose of this paper is to outline the responses received. (ii) Schools were asked to respond to the following five questions: - 1. Are you satisfied with the amount of time that the school nurses provide to your school? 2. On average, how often does the school nurse visit your school? 3. How important to your school is the school nursing service? 4. What do you see as the priorities of a school nurse? (Schools were asked to rank in priority order up to three priorities from a list) 5. Do you wish to add any additional comments on school nursing? (iii) This Appendix sets out the responses to the survey by phases of school: - (1) Primary Schools (2) Secondary Schools (3) Special Schools (4) Pupil Referral Units 6 The term primary school includes infant, junior and nursery schools. 7 The term secondary school includes comprehensive, secondary modern and grammar schools. 8 Solutions 4 is counted as one pupil referral unit. 10

1. PRIMARY SCHOOLS Satisfaction with School Nurse Time Allocated 1.1 The first question in the survey was: Are you satisfied with the amount of time that the school nurses provide to the school? 1.2 51% of primary schools responded No to this question. 44% gave an affirmative answer. 5% of primary schools expressed no opinion. The results were also analysed by district council area and there were variations in the answers received. For example, schools in North Kesteven and West Lindsey were least satisfied, while schools in Boston Borough and South Kesteven were most satisfied with the school nursing time received. District Council Area No Yes No Opinion Boston 67% 33% 0% East Lindsey 44% 50% 6% Lincoln 25% 56% 19% North Kesteven 31% 69% 0% South Holland 56% 44% 0% South Kesteven 67% 27% 7% West Lindsey 30% 70% 0% Total 44% 51% 5% 1.3 It must be stressed that these figures reflect dissatisfaction with the amount of time allocated to the school and not to the quality of school nursing received. Responses to Question 5 in the survey showed that many schools were highly complimentary about the support that they received from their individual school nurse. Frequency of Visits 1.4 The second question in the survey was: On average how often does the school nurse visit your school? 1.5 The results indicated that 15% of primary schools received a visit from their nurse at least every fortnight. 26% of primary schools receive a monthly visit. 37% of schools receive a termly visit from their nurse. We suggest that the discrepancies in the frequency of visits is explained by the size and need of respective primary schools. Importance of the Service 1.6 Schools were asked to respond to the question: How important is the school nursing service? in one of the following ways: very important, important no opinion, not important or not at all important. The response to this question 11

was an emphatic statement that the service is very important for schools. No school indicated that the service was not important or not at all important. 1.7 71% of primary schools indicated that the school nursing service was very important. A further 28% indicated that the service was important. Only three primary schools (2% of respondents) expressed no opinion on this matter. Priorities for School Nursing 1.8 Schools were asked to respond to the question: What do you see as the priorities of a school nurse? Schools were asked to rank up to three priorities in order from the following list: Child Protection and Safeguarding Advising on Pupils with Complex Needs Co-ordination of Immunisation Programmes Health Education / Promotion Developing a School Health Plan Supporting Teaching Staff First Point of Contact for Parents / Carers Other 1.9 40% of primary schools identified health promotion and education as the highest priority. 28% of primary schools identified the child protection and safeguarding as the highest priority. 26% of primary schools identified nurses being the first point of contact for parents and carers as the highest priority. 1.10 A similar picture emerges, when the highest three priorities are considered. However, the responses to this question indicate clearly that different schools have different priorities, depending on their own particular circumstances. Additional Comments 1.11 Schools were asked: Do you wish to add any additional comments on school nursing? A total of 123 primary schools (74% of the schools who responded) submitted additional comments. A full set of comments (by district council area) is available separately. Many of the comments were complimentary of the individual nursing services provided. A selection of these is set out below: - Our new nurse is fantastic. Thank you. (Primary School in West Lindsey) Our school nurse is extremely supportive and always responds promptly when we have any issues. (Primary School in Boston) Our school nurse is an integral part of our aim to achieve the five Every Child Matters outcomes. The support and information we share helps us provide for the very clear needs of children in this area of multiple deprivation. (Primary School in East Lindsey) 12

Having a school nurse available to answer questions from parents has been excellent. She can always be contacted within 24 hours, or return calls within this time. (Primary School in North Kesteven) Our school nurse is very beneficial both to support staff, but also parents and offer them advice. She is an excellent source of information and support. (Primary School in Lincoln) We value our school nurse greatly. (Primary School in South Kesteven) Our school nurse is excellent, helpful and understanding. He just never has enough time. This man in undervalued as will all school nurses. (Primary School in South Holland) 1.12 Many schools used this part of the survey form to reiterate their views about the amount of school nurse time allocated. A selection of these comments is set out below: - We would like far more school nurse time (Primary School in South Kesteven) As we move closer to extended school provision, it would be good to have more access to the school nurse not less, as seems the case. Supporting two key elements of the Every Child Matters agenda, we need more support, not less. The need for school nurse support is increasing, not decreasing. (Primary School in South Holland) The school nurse is a valuable resource to us. It is a pity the service has been reduced so much. (Primary School in West Lindsey) The school nurse is really valued by staff and parents. We would very much appreciate an opportunity to extend first contact with parents / carers. (Primary School in East Lindsey) I would like to see the school nurse in school more often. (Primary School in Boston) A lack of consistency in provision makes medium and long term planning extremely difficult. (Primary School in Lincoln) If our school nurse had more time, we would invite her into school far more frequently, to work with parents and with children. (Primary School in North Kesteven) 1.13 Other issues were also raised in the additional comments. There were several comments on the school nurse role in Common Assessment Framework (CAF) meetings. The following are examples of the comments: - Concern that under CAF too much sitting in meetings, especially if health is not an issue. (Primary School in East Lindsey) 13

The demands of CAF meetings reduce the time with children and families. Schools need a medical contact to ensure Every Child Matters agenda is met. (Primary School in Lincoln) It is essential that the school nurse s role is retained and increased. The school nurse is the only link to health. GPs are not interested in attending Common Assessment Framework, etc. (Primary School in North Kesteven) More time is needed to utilise their skills more effectively across the health education agenda. Our nurse has been very supportive and helpful in school and at CAF meetings. (Primary School in South Kesteven) 1.14 Other issues raised included sex and relationships education. Why is the sex education programme no longer a priority for the school nursing service? (Primary School in East Lindsey) Before recent cuts in funding for school nurses we had an excellent working relationship with our school nurse. She supported parents, attended child protection cases, helped deliver sex education and worked with healthy lifestyle promotion. These are key priorities and I would like to see a return to this set up. (Primary School in Lincoln). 2. SECONDARY SCHOOLS Satisfaction with School Nurse Time Allocated 2.1 The first question in the survey was: Are you satisfied with the amount of time that the school nurses provide to the school? 2.2 58% of the secondary schools who responded to the survey were not satisfied with the amount of school nurse time allocated. The remaining 42% of secondary schools were satisfied. As with primary schools, the questionnaires figures have been analysed by the seven district areas, but as there are a relatively small number of secondary schools in some districts, these findings are not presented in this summary report. Frequency of Visits 2.3 The second question in the survey was: On average how often does the school nurse visit your school? 2.4 The results of the questionnaire showed that secondary schools were visited much more frequently than primary schools. For example, 53% of secondary school reported a school nurse visit on average once per week and a further 32% reported a visit every fortnight. This reflects the fact that secondary schools as larger organisations are going to generate the need for more school nurse contact time. However, four secondary schools reported only a monthly visit and two schools indicated that they were visited less often. 14

Importance of the Service 2.5 Schools were asked to respond to the question: How important is the school nursing service? in one of the following ways: very important, important no opinion, not important or not at all important. The response to this question was an emphatic statement that the service is very important for schools. No school indicated that the service not important or not at all important. 2.6 For 92% of secondary schools the school nursing service is very important. For the remaining 8% of secondary schools the service is important. As with the findings for other phases of education, this is an emphatic statement asserting the importance of the school nursing service. Priorities for School Nursing 2.7 Schools were asked to respond to the question: What do you see as the priorities of a school nurse? Schools were asked to rank up to three priorities in order from the following list: Child Protection and Safeguarding Advising on Pupils with Complex Needs Co-ordination of Immunisation Programmes Health Education / Promotion Developing a School Health Plan Supporting Teaching Staff First Point of Contact for Parents / Carers Other 2.8 Secondary school first priorities differ from primary schools. 45% stated that child protection and safeguarding was the highest first priority. A further 29% of secondary schools identified health promotion and education as the highest priority. 2.9 There was a clear response from secondary schools on the highest three priorities: 89% of secondary schools identified health promotion and education as one of the three highest priorities; 85% of secondary schools identified child protection and safeguarding as one of the highest three priorities; and 82% identified receiving advice on children with complex needs as one of the three highest priorities. Additional Comments 2.10 Schools were asked: Do you wish to add any additional comments on school nursing? A total of 31 secondary schools (82% of the schools who responded) submitted additional comments. A full set of comments (by district council area) is available separately. A selection of the most complimentary comments is set out below: - Our school nurse is pro-active and will come into school when requested to support the students. (Secondary School in Boston) 15

The school nurse is the first point of contact for pupils with health concerns and also advises staff who have concerns regarding students. The drop in clinic is very beneficial to students. (Secondary School in West Lindsey) Our school nurse is vital. (Secondary School in North Kesteven) Our school nurse has been excellent in supporting both staff and students. Her experience and approachable nature have meant that she has been invaluable in helping to break down barriers and act as a catalyst for change / communication in difficult situations. She has helped pastoral colleagues to agree with extremely difficult situations which could have led to serious problems for individual students and their families. We cannot put a price on the value of her contribution to the school s inclusion policy and Every Child Matters agenda. Our nurse is a first class professional. (Secondary School in South Holland) We have a fantastic school nurse who works incredibly hard. She has no admin assistance which she needs for the many child protection meetings she attends. She works well with all our staff and is professional and helpful. We would like her to be based on the school full time. (Secondary School in South Kesteven) 2.11 As with primary schools, some secondary schools used the additional comments section to reiterate their views on the amount of school nurse time allocated: Over the last two years the school nursing provision has been particularly poor. We have shared our nurse with a wider group of schools than normal. This has led to a very thin emergency, reactive, service. This has been far from ideal. (Secondary School in West Lindsey) We would like to see our school nurse have a higher profile, with more time allocate to the children in our school. (Secondary School in Boston) The nurse used to be available to do Sex and Relationships Education lessons. We would like her to do this again. (Secondary School in Lincoln) Eight years ago our cluster benefited from two full time nurses. We now have one part timer. Although she is excellent, she simply does not have enough hours in the day. (Secondary School in South Holland) I recently had correspondence with the school nurse team, arguing for the maintenance of the school nurse teaching programme in Personal, Social and Health Education, which we have had in the past, rather than the drop-in sessions, which are little used by students. I was told that the drop-ins are a legal obligation and there was not sufficient staffing for the teaching programme. I would still like to see a return of the school nurse in the teaching programme, with drop-ins available, if possible as well. (Secondary School in West Lindsey) 16

3. SPECIAL SCHOOLS Satisfaction with School Nurse Time Allocated 3.1 The first question in the survey was: Are you satisfied with the amount of time that the school nurses provide to the school? 3.2 Only 38% of special schools were satisfied with the amount of school nurse time allocated. This is the lowest level of satisfaction of any group of school. Frequency of Visits 3.3 The second question in the survey was: On average how often does the school nurse visit your school? There was a range of responses to this question. Two schools received weekly visits. Three schools were visited weekly, while four schools were visited each month. The other four schools gave other responses to this question. Importance of the Service 3.4 Schools were asked to respond to the question: How important is the school nursing service? In one of the following ways: very important, important no opinion, not important or not at all important. The response to this question was an emphatic statement that the service is very important for schools. No school indicated that the service not important or not at all important. 3.5 Ten (77%) of the special schools that responded to the survey rated the school nursing service as very important. The remaining three schools rated the services as important. Priorities for School Nursing 3.6 Schools were asked to respond to the question: What do you see as the priorities of a school nurse? Schools were asked to rank up to three priorities in order from the following list: Child Protection and Safeguarding Advising on Pupils with Complex Needs Co-ordination of Immunisation Programmes Health Education / Promotion Developing a School Health Plan Supporting Teaching Staff First Point of Contact for Parents / Carers Other 3.7 Five special schools (38%) considered that advising on complex needs was the highest priority for the service. A further five schools stated that health education and promotion was the highest priority. 17

3.8 In terms of the highest three priorities advising on complex needs was identified by 85% of special schools and health education and promotion was the identified as one of the highest three priorities for school nursing. Advising on pupils with complex needs was identified as a top priority by 46% of special schools as one the top three priorities. 3.9 As with both primary and secondary schools used the additional comments section to reiterate their views on the amount of school nurse time allocated: The school nurse plays a crucial and integral part in addressing the needs of our pupils. Her input is both vital and valuable. If children s services are to be truly central to meeting the needs of our pupils, then adequate time must be provided, otherwise nothing more than skimming the surface will be achieved. (Moderate Learning Difficulties Special School) Better provision is essential the complexity of our pupils is increasing, yet over the last five years there has been a great decrease in the amount of time our school nurse has been able to spend with us. Working with special needs pupils and their parents requires ongoing knowledge of them and the building of trust between them so that they are supported appropriately. (Severe Learning Difficulties Special School) 3.10 It was clear from the comments of the special schools that there are particular issues pertinent only to special schools. It is essential we keep the nurses for children with disabilities involvement for training. We need more nurses who are trained to work with our pupils (and parents of disabled children.) (Severe Learning Difficulties Special School) School nurses are vital to the needs of pupils at this school as the majority of pupils attending here have complex medical needs and nurses here advise and support school staff and residential staff and parents. They also play an important role in the promotion and delivery of health education. (Physical and Medical Needs Special School) I would refer you to North East Lincs provision of a specialist school nurse for its two special schools, pre-school and home service. We have nothing like this in Lincolnshire, although we have the Specialist Health Advisor service. This is very stretched and at a minimum level for the schools in Lincolnshire. (Severe Learning Difficulties Special School) 4. PUPIL REFERRAL UNITS Satisfaction with School Nurse Time Allocated 4.1 The first question in the survey was: Are you satisfied with the amount of time that the school nurses provide to the school? We received two responses from the County s five pupil referral units. One pupil referral unit was satisfied by the amount of school nurse time allocated and the other unit was not. 18

Frequency of Visits 4.2 One unit referred to visits once per term or by appointment. The other unit reported that it was not visited at all. Importance of the Service 4.3 Schools were asked to respond to the question: How important is the school nursing service? Both units stated that the service was very important. Priorities for School Nursing 4.4 In response Schools were asked to respond to the question: What do you see as the priorities of a school nurse? Schools were asked to rank up to three priorities in order from the following list: 19