At our annual conference in 2023, Jamie Waterall, England's Deputy Chief Public Health Nurse urged school and public health nurses to be ‘bold and lead change’, he went on to say school and public health nurses are ‘perfectly positioned’ to shape, lead and deliver on policies to improve the nation's health (SAPHNA, 2023). The Change NHS consultation to ‘help build a health service fit for the future’ is an opportunity for school and public health nurses to speak up, share their expertise, give their views and help policy makers shift health care from hospital to the community, from sickness to prevention and to improve the use of technology.
On December 24, Jamie opened our webinar, attended by school nurses and public health nurses and their teams. His message was clear, public health nurses need to have their say and respond on a professional level to the Change NHS consultation. Jamie and Lynn Reed, deputy director 0–19 Clinical Programmes Unit, joined the breakout room discussions where attendees explored and debated each ‘shift’ area, thinking about how outcomes for school-aged children and young people might be improved, and how school nursing might contribute to these changes and help build a health service fit for the future. The event closed with an address from Duncan Burton, Chief Nursing Officer for England.
The 10-year health plan is built on three shifts, hospital to community, analogue to digital and sickness to prevention. It is unsurprising that school and public health nurses had much to say about how healthcare can change. Prevention is core to our specialist public health role and care in the community is key to being visible and accessible to all school-aged children and young people, whether they in education settings or the community in which they live.
‘As school and public health nurses, we know only too well that treating illness is more expensive than preventing it and that ill health affects all aspects of children and young people's lives, and that of their family and friends.’
Shift 1: Hospital to community
As school and public health nurses, we know only too well that treating illness is more expensive than preventing it and that ill health affects all aspects of children and young people's lives, and that of their family and friends. There are long waiting times for diagnosis and treatment which can have a negative impact on outcomes. Webinar participants discussed the need to invest in community services, to have a health ambition for all children, antenatally, through their school years and into adulthood and have a broader focus than providing clinical intervention or treatment for illness, expanding ‘care’ to include prevention and early intervention. They talked about the need to shift the focus to helping people to take responsibility for their own health at an early age, for example, improving health education in schools and community settings and resourcing services so they can provide early intervention to prevent progression of illness and crisis.
The SAPHNA inaugural survey of school nurses across the UK, ‘The Forgotten Frontline’ highlighted a postcode lottery of provision, leading to inequality in the delivery of the Healthy Child Programme (HCP) 5–19. During the webinar, school nurses spoke about how this inequality needs to be addressed, the HCP 0–19 is an evidence-informed framework of promotion, prevention and early intervention to improve outcomes for children and a failure to deliver presents a missed opportunity to improve health outcomes for children and young people and reduce the burden of ill health. They called for all touchpoints in the HCP 5–19 to be mandated so that children and young people have access to health reviews and contacts. If this is achieved then all children will have access to high quality, evidence-based promotion and health education and there will an increased opportunity for early identification of health problems. Proper monitoring of delivery will generate essential data about service provision and evidence the impact on health outcomes, supporting future service improvement. Of course, effective delivery of the HCP 5–19 needs a properly resourced workforce. School nurses called for commissioned services to be accessible and visible, available at the times that service users need them or in places that are accessible. For example, school nursing services, available at times extending beyond the school day and in settings broader than education settings.
Shift 2: Analogue to digital
The national consultation brief outlines the challenges that reliance on paper and pagers, outdated computers and software brings to parts of the NHS. The uneven use of modern technology creates a postcode lottery, access to the latest treatments often depends on where you live. An outdated and poor technology impacts on retention of staff. SAPHNA (2024) heard these themes echoed in the responses to our inaugural survey and in discussion in the webinar. School nurses told us that systems do not talk to each other, there is often duplication, recording information in more than one system and challenges with systems not communicating with one another. They called for an improvement in IT systems so they talk to each other, removing the barriers, for example, multiple, unconnected systems which risk information not being shared and make elements of the role, including clinical record keeping time consuming for clinicians which has a negative impact on time left to be spent with children and young people. Worryingly, school nurses working for non-NHS providers highlighted that they no longer had access to NHS IT systems and this left gaps in their understanding of the journey of the child, introducing risks including keeping children safe. Technology development needs to include how systems for NHS and private/independent providers link and share information.
School nurses are used to leading the way, using technology to deliver care to children and young people. The COVID-19 pandemic saw the necessity to rapidly shift from ‘in person’ contacts to virtual provision. School nurses responded by finding ways to provide ‘drop-in’ sessions, deliver health reviews, intervention and health education using digital approaches. The use of text services, websites and digital health needs assessment is well embedded in some services. During the webinar school nurses discussed the importance of ensuring that technology does not simply replace in person contacts, becoming a mode of delivery to save money but rather a shift to technology enhances care, improves choice and is supported by robust governance to ensure safe, highly quality and effective care is maintained. They recognised the challenges of technology for some children and young people. For example, school nurses working with children with additional needs highlighted the need to design websites so they are accessible to those with neurodiversity, and staff using text provision are supported to adapt communication which are tailored to meet the needs of those children with additional needs. Barriers of digital poverty and digital hesitancy were debated, and it was identified that the extent of these barriers needs to be assessed and then addressed to avoid exclusion of children in families that do not have access to technology or are reluctant to use digital healthcare. School nurses also highlighted a need for co-production of technological solutions to ensure that it meets the needs of children and young people, and their voices are heard and responded to.
School nurses called for investment in the digital health needs assessments (HNAs) for each key contact point in the HCP 5–19 is an opportunity to provide a more standardised digital approach, supporting the identification of population needs across local and national levels to inform future service delivery as well as responding to the health needs of individual children and young people. SAPHNA's inaugural survey evidenced the inconsistent approach to the delivery of HNA's in HCP 5–19, they are not carried out in all areas and those areas that do them differ in the approach, some are still paper-based and of digital, there is a range of different systems used.
‘School nurses told us that systems do not talk to each other, there is often duplication, recording information in more than one system and challenges with systems not communicating with one another.’
‘… school nurses told us that they had seen an increase in children and young people needing support in almost all areas of health and wellbeing need, including mental health, weight and dental problems.’
Shift 3: Sickness to prevention
The government wants the nation to stay healthier for longer and recognise that more work is needed to prevent ill health. Smoking is the cause of 25% of cancer deaths, more than half of our nation is overweight or obese and levels of poor mental health have risen – this is now the main health-related cause of people being unemployed. In SAPHNA's (2024) survey, school nurses told us that they had seen an increase in children and young people needing support in almost all areas of health and wellbeing need, including mental health, weight and dental problems. School nurses know that focusing on promotion and prevention will support children and their parents/carers to make healthier choices, preventing illness and offering intervention earlier, which will support better management of illness and long-term conditions. During the webinar, school nurses discussed that services need to be commissioned in a way that allows school nurses to be proactive, identifying and responding to the needs of the populations that they serve, working appropriately with other services to improve outcomes, shifting away from the reactive, downstream approach that has become a way of working in many areas because services are poorly resourced. They also emphasised the importance of viewing children and young people's needs holistically, focusing on issues that if not addressed have the potential to impact negatively on health and wellbeing and having wider negative social and economic impacts. For example, intervening early to address social determinants that might lead to poor school attendance and/or inability to engage in education which can lead to social exclusion and poor employment opportunities later in life. School nurses are ideally placed, if properly resourced, to play a significant role in the prevention agenda, this is what they are trained to do. For example, providing health education and early intervention to improve oral health, healthy growth, respond to childhood continence problems, improve uptake of immunisations and support children and young people with anxiety and low mood. However, investment is required for school nursing services to provide holistic assessment of needs at all key contact points in the HCP 5–19, offer health promotion opportunities, advice, and support early where appropriate, preventing escalation of health and wellbeing issues. Some school nurses suggested that reintroducing ‘healthy schools’ awards, encouraging a multi-agency approach to whole school approaches to health and wellbeing will strengthen the prevention agenda.
The webinar generated so much discussion and I have tried to capture a flavour of this in this column. Now it is over to you. Have you had your say? It is not too late. Register and share your public health expertise and experience, tell our policy-makers what needs to change. Join the conversation: https://change.nhs.uk/en-GB/folders/in-case-you-missed-it
In addition to completing the formal consultation questions, you can post your ideas: https://change.nhs.uk/en-GB/projects/your-ideas-for-change