Which of the Following Health Problems Continues to Increase in School aged and Adolescent Children

Foreword

"School nurses provide a vital and unique link between school, home and the community. They are there from the start of primary school all the way through to secondary school and on to young adulthood. Throughout these years they guide and support children and help promote good physical and mental health.

From being at forefront of spotting signs of abuse to encouraging healthy eating and providing immunisations, the range of services they provide is wide and far-reaching.

But it goes further than that. They are there as a trusted shoulder to cry on and provide an ear to listen. They support children through difficult transitions, whether it is starting school, moving to secondary school or providing advice on sexual health.

In doing so, they play a key role in reducing health inequalities, reaching out to vulnerable and marginalised young people who may otherwise fall through the gaps.

When children are not healthy, their ability to learn, develop, and thrive is affected.

Children's health across the UK has worsened over the past decade; levels of obesity and mental health problems have increased, whilst physical activity levels continue to be lower than pre-March 2020 levels and rates of routine immunisation have fallen.

Over a quarter of children aged 10-11 were living with obesity in 2020-21, compared with twenty one percent the previous year. Children living with obesity are more likely to become adults living with obesity and are at a greater risk of poor physical health outcomes in later life, such as high blood pressure and diabetes. It can also affect a child's self-esteem and emotional wellbeing.

Children's oral health is also a significant priority; tooth decay is still the most common dental disease that affects children. It can result in significant pain and eventual tooth loss, with an adverse impact on school attendance and the wellbeing of themselves and their family.

Mental health and emotional wellbeing have never been as important as they are now. Recent studies suggest that one in six young people have a mental health problem in 2020, rising from one in nine in 2017 and three quarters of mental health problems emerge before the age of 24. Children and young people with mental health problems are more likely to be excluded, and they are also more likely to come from poorer households.

School nurses provide a key role in identifying children's needs, signposting to appropriate services and providing health promotion messages and targeted evidence-based interventions. This plays a vital part in the reduction of child health inequalities through a holistic approach to identifying and addressing the health needs of children.

Their support is needed now more than ever as our young people recover from the impact of the pandemic. And, as this collection of case studies shows, school nurses are rising to the challenge.

There are examples of services with dedicated teams for children with special educational needs, projects that support the mental and emotional health of pupils and an integrated team in Warwickshire that works with children and families to tackle child obesity.

They are though just a few examples of the work school nurses do up and down the country. The range and breadth of initiatives they are involved with and the impact they can have is immense.

But there is a common thread that unites all this work – school nurses championing children and young people, supporting them to fulfil their potential and navigate the challenges of growing up."

Cllr David Fothergill, Chairman, LGA Community Wellbeing Board

School nursing: A brief history and their importance

Britain's first school nurses emerged in the early twentieth century as a result of political and societal pressures to improve the health of children living in poverty and to reduce the number of children missing school due to minor ailments.

A concurrent report published by the British army stressed the need to focus on improving child health as over half of young men who had volunteered to join were medically unfit for service. Many treatable conditions had been left untreated and poor nutrition amongst volunteers was a key factor for poor health.

In 1907, an Act of Parliament was passed to introduce the medical inspection of children in school; this included measuring the height and weight of pupils to assess their health and wellbeing. This is broadly still in place over 110 years later, this time in the form of the National Child Measurement Programme which assesses the growth of over one million children annually aged 4-5 and 10-11.

School nurses worked to treat disease and illnesses and to promote overall child health, alongside other medical professionals. This reduced the burden on local health services such as GPs and hospitals. They took on other vital roles, such as health protection and identifying and excluding those at risk of (or infected with) an infectious disease.

In 1974, school nurses were moved to work within NHS community services. The role has developed over time and school nurses are now more autonomous, working as system leaders and building partnerships with families and the local communities to lead initiatives for children and young people.

In 2004, formal Nursing and Midwifery Council (NMC) approved standards for a post-graduate qualification in school nursing were developed. This is known as a registration in specialist community public health nursing (SCPHN – SN).

Since April 2013 Local Authorities have been responsible for commissioning public health services for school-aged children (5-19). This presented new opportunities to improve outcomes for young people, with a focus on prevention and the wider determinants of health.

Many early ambitions of the school nursing service are still in place today; school nurses are once again commissioned by local authorities, and they still play a vital role in reducing health inequalities and protecting the health of all school-aged children and young people.

The role explained

School nurses lead on delivering the five to 19 elements of the Healthy Child Programme in England. They are registered nurses or midwives, who have undertaken additional postgraduate training and qualifications to become specialist community public health nurses (SCPHN - SN).

They are supported by skilled, mixed teams of staff, including nursery nurses and community staff nurses.

School nurses also work alongside other members of the children's workforce, including GPs, health visitors and voluntary services. And they, of course, partner closely with schools, also providing training for staff and supporting the development of relationships and sex education.

School nurses are system leaders and system connectors; working with parents, carers, families and other key agencies to identify the most suitable intervention for the child or young person (or / and at a population level) to improve health outcomes. School nurses use the most up-to-date evidence base to deliver effective and comprehensive interventions for children and young people and engage in wider health promotion activities, such as Making Every Contact Count and developing whole school approaches to address health inequalities.

Working with parents and families and partner agencies, school nurses identify the most appropriate level of support and intervention for individual and population needs. Although school nurses provide leadership, they will need to work with partners to deliver a comprehensive programme of evidence-based interventions.

They are uniquely placed to develop trusting relationships with children and young people, their parents, their school and the local community. The confidential and accessible support provided by school nurses throughout a child's time in education allows children and young people to thrive and develop health promoting behaviours as they progress into adulthood.

School nursing follows what is known as the "Universal in reach – Personalised in Response" delivery model

This is based on four levels of support depending on the needs of the child or young person and their family:

• Community – the wider role of leading public health within schools and contributing to the wider assessment of health needs. This also includes utilising community-based assets or strengths.
• Universal services – leading and coordinating evidence-based services and programmes, this could include drop-in clinics and signposting to other services.
• Targeted – providing early help to those children who require additional services such as for emotional health and wellbeing.
• Specialist – involvement in providing additional services to vulnerable children and families with specific problems requiring coordinated input from a range of professionals. This could require referrals to an additional specialist service or additional signposting, working in partnership with other agencies.

School nurses will holistically assess the needs of the child to determine, as required, the most suitable intervention, or whether any additional specialist interventions or additional support is required.

The needs of the child and their family may change over time or due to their circumstances, so the level of support required will be tailored by the school nurse accordingly.

Safeguarding children underpins all aspects of the model due to the key role school nurses play in keeping children safe and supporting local safeguarding arrangements, such as working closely with other key agencies.

There are seven suggested universal health reviews at key development stages:

• Four to five-year-old health needs review; this could include assessing immunisation status, speech and language skills and healthy weight.
• Seven- to eight-year-old needs contact; this could include brief interventions around supporting emotional and mental resilience.
• 10 to 11-year-old health needs assessment; this could include supporting the transition to high school and providing information around healthy weight.
• 12- to 13-year-old health needs assessment; this could include providing information about healthy relationships and sexual health, and promoting uptake and delivering the HPV vaccine (human papillomavirus).
• School leavers post 16 health needs review; this could include supporting with emotional and mental resilience and preparing for transition to work or further education.
• Transition to adult services; this could include supporting young people as they move into adulthood and become more autonomous or require support in managing their health and care needs.
• 18 to 24-year-old health needs review; for children and young people with additional vulnerabilities, such as those who are care experienced or with special educational needs and disabilities.

And because of the wide range of issues covered, school nurses have been tasked with focusing on six broad high impact areas where they can have a significant impact on health and wellbeing and reducing inequalities. They are:

• supporting resilience and wellbeing
• improving health behaviours and reducing risk-taking
• supporting healthy lifestyles
• supporting vulnerable young people and improving health inequalities
• supporting complex and additional health and wellbeing needs
• promoting self-care and improving health literacy.

Why are school nurses an important resource for schools?

School nurses have long played an invaluable role, supporting children and young people with both their physical and mental health in a safe and supportive environment, using evidence-based interventions.

They are on the frontline of spotting problems such as abuse and mental health support needs in vulnerable young people, as well championing healthy eating and providing immunisation and health protection services.

From early intervention services to dealing with serious youth violence, school nurses have a significant, positive effect on young people's lives which benefit them both within and beyond the school gates. Their pastoral, supportive role is needed now more than ever as our young people continue to recover from the impact of the pandemic and during the ongoing cost of living crisis.

If we want our children and young people to reach their full potential in adulthood, providing access to school nurses who are specialists in public health and early intervention is fundamental.

The LGA has long called for an increase in the public health grant to enable councils to commission a school nurse for every secondary school and cluster of primary schools as well as a comprehensive workforce plan to address shortages.

Acknowledgements

With thanks to colleagues at the School and Public Health Nurses Association (SAPHNA) for their valuable contributions and feedback for this piece of work.

Thanks also to colleagues at the Association of Directors of Public Health (ADPH) and the Office for Health Improvement and Disparities (OHID).

Key questions to ask

• How are school nurses making every contact count? For example, are they using the contacts they have to unearth issues that need addressing, such as young caring responsibilities?
• Have the school level health needs assessments and aligned plans been completed? These should contain information about the local area, levels of deprivation and ethnicity of schools
• The National Child Measurement Programme is a rich source of data. Are there programmes in place to help children who are overweight?
• Is there a dedicated service for children with special educational needs? If not, how are their health and wellbeing needs being met?
• Are school nurses equipped to deal with gender-related issues and arising questions? Have you considered extra training in LGBT+ issues?
• Do school nurses have the skills to deal with mental health problems? And how are they working with local mental health services?
• Are children being asked about their own health and experience of the school health service? Are they involved in co-production?
• Do school nurses offer parental and family workshops covering a range of health issues including emotional health and well-being
• Do your school nurses have a virtual offer, for example a text service for young people and parents or an online drop-in clinic?
• Are there well-established referral pathways to and from services, such as GPs and social care?

Case study: Derby - Supporting children from asylum seeker families

A dedicated team has been set up in Derby to support children from asylum-seeking families. It is part of the 0-19 Derby Integrated Family Health Service and involves two public health nurses dually qualified as health visitors and school nurses, a family health practitioner and child practitioner.

"We go knocking on doors"

Derby is one of the Home Office's dispersal locations for the East Midlands. It means when asylum-seeking families arrive, they are housed in the city while applications are processed, and more permanent homes can be found.

There are nearly 100 properties that are used to house the asylum seekers along with a 140-bed bridging hotel that has been used for Afghan refugees over the past year where they are triaged until they are offered permanent housing in locations across the country. On top of that the city is seeing increasing number of Ukrainian refugees arriving as local residents offer up their homes under the government's Homes for Ukraine scheme.

To help support children from asylum-seeking families, the council and NHS have funded a specialist team to provide both support for health and wellbeing and wider social support. It was established in the summer of 2021 and has been formed from staff from the council and Derbyshire Healthcare NHS Foundation Trust, which is commissioned to provide the 0-19 service.

It means when new children arrive with their families, the public health nurses, family health practitioner and child practitioner will carry out a health assessment. "We literally going knocking on doors," said Virginia Hickman, the Specialist Community Public Health Nurse for Asylum Seeking Families. "That is often all we have – an address. Our immediate priority is to assess the health needs and check the children are up to date with their vaccinations. We then liaise with the local GP surgeries that update their routine childhood vaccinations and COVID record as needed.

"We have an additional qualification in prescribing so if they need medications for things like skin infections or other conditions, we can do that. Often these families have been living in pretty awful conditions before arriving in Derby so we find problems such as scabies can be common. We have also identified cases of TB that need treating.

"If the child has a specific long-term condition, like diabetes or asthma, we put them in touch with a specialist nurse. We help explain to them how the health system works."

Supporting wider social needs

The wider social and wellbeing support is coordinated by the child practitioner, Sian Hallam. She is part of the council's social care team so can arrange for early help or deal with safeguarding issues.

Ms Hallam said: "These families obviously have a variety of needs. Mental and emotional health support is often needed – although we find that it can take a few weeks for that to hit them. When they first arrive, there is a flight or fight tendency. We can also arrange things like Sure Start grants and really just answer any questions they have. One of the aims is to reduce reliance on services such as A&E.

"The idea is we provide support for the first six weeks and then we hand them over to the universal services. Many will move out of the area. But the ones that do stay we can provide ongoing support if they are really vulnerable or complex.

"For example, we have had cases where children have been bullied or been really unhappy and distressed when they have started in a local school. Because we are trusted by the families, we will continue working with them."

Why building trust is key

Building trust with these families is a big part of the team's work. Ms Hickman said: "We do find that some families do not want to immediately engage with us. They have been through so much and understandably are suspicious.

"There are also cultural sensitivities to navigate. You need to be aware of that to be able to support the family considerately."

Another challenge is the language barriers. The team use the telephone translation services that are available via the NHS and council, but there are other methods too. "Sometimes it is a matter of making use of online services, even Google Translate sometimes. We also find family and community members may have good English language skills that can be utilised," added Ms Hickman.

"You have to take it step by step. If they are not happy to talk to us during the first visit, we come back. Sometimes it can take a few weeks before they are willing to accept our help. We just make sure we are as visible as possible, and we even do a drop-in once a month at a women's refugee group. It really helps us access those struggling to access our services. You have to be patient."

Contact details

Virginia Hickman, Specialist Community Public Health Nurse for Asylum Seeking Families, Derby Integrated Family Health Service: virginiahickman@nhs.ne

Case study: Stockport - The benefits of school nurses offering immunisations

In many areas school-based immunisation programmes are run separately from 5-19 Healthy Child Programme services, but that is not the case in Stockport where the HPV, the teenage three-in-one booster and MenACWY vaccines programmes are delivered by the service.

The approach has helped ensure high uptake of immunisations and meant the service was well placed to respond to the demands placed on it by the pandemic.

Immunisation is an opportunity to engage pupils

Stockport's school nursing service is delivered by Stockport NHS Foundation Trust and is part of Stockport Family, an integrated Stockport Council service. The team consists of specialist public health school nurses, a children's continence team, a complex safeguarding nurse and the immunisation team, which focuses on school-based immunisations.

Stockport is a relatively small borough – there are around 14,000 young people within the 12–15-year-old cohort – within this there are significant differences in health inequalities.

School Nurse Team Lead Anne-Marie Gallogly said: "We have some very affluent areas and some very deprived areas. That creates a lot of challenges with immunisations, but having the immunisation offer within the school nursing service helps us to address some of those inequalities.

"There are several benefits to the model we have. The school nurses know the schools, the layout of the buildings and the children and their families, there are already good relationships with our colleagues in education. They are trusted – and that is of major significance when it comes to immunisations. They are aware of the young people from whom you may not get parental consent and the most vulnerable young people and can engage with families when appropriate.

"Each school has a named school nurse so when the immunisation team go in the school it is the named nurse that leads the immunisation session. It is a valuable opportunity to engage pupils. We find they will often disclose other issues – eg anxiety, mental health concerns, sexual health or safeguarding issues.

"We are proactive too - we also talk to them about our service and how they can get in touch with us. During the COVID immunisation programme we were able to use the time the young people spent with us talking about a new online offer - Chat Health. This is a confidential new text messaging service that enables children and young people aged 11-19 to contact the Stockport school nursing team about any health queries or concerns they may have.  A school nurse will then get back in touch with the person who has contacted them to offer health advice and support.

"It is about making every contact count. You don't get that if the services are separate."

Meeting the challenges of the pandemic

The set up proved hugely beneficial in terms of meeting the challenges that emerged as a result of the pandemic. The first lockdown in spring 2020 meant that immunisation services across the country fell behind in their HPV and three-in-one teenage booster vaccine programmes.

Stockport school nurses responded by setting up a vaccination clinic in a local church hall over the summer holidays in 2020. More than 1,000 children were vaccinated. Parents really appreciated the offer. One said: "I was so impressed with how organised it was – it worked like clockwork."

Then, when the child COVID vaccination programme got under way in September 2021, the team combined those with routine immunisations.

Ms Gallogly said: "It was a huge undertaking and resulted in a very intense few weeks. We were determined that we did not want the other routine vaccinations to stop so we did both."

This was achieved with help from the public health team at the council as the local COVID advice and testing team worked with the service to help with the admin side of the children's COVID vaccination programme for the first dose.

The COVID-19 testing team went in with the school nurses and immunisation team to support with some of the data entry requirements. The arrangement worked well - Stockport had the highest uptake for the first dose in Greater Manchester with an uptake of 64 per cent.

"The pandemic has actually helped to build new relationships like that," said Ms Gallogly. "And then when the second doses needed to be done, we were actually able to train the testing team as vaccinators under the national protocol that was allowed. They had seen what it entailed and had the support of our nurses."

Other steps were also taken, including establishing a half-term catch up clinic at a local church to offer COVID vaccines to those who had not yet been vaccinated or were being home educated and had not had the chance to get vaccinated in school. A clinic for children and young people with needle phobias was also offered to allow those who were too anxious to access vaccines in school to have their vaccinations.

But now that is complete, the school nursing service is back prioritising routine vaccinations. Ms Gallogly said: "Immunisation is so important that we cannot let uptake drop. The focus and controversy over the COVID vaccine has affected other vaccines with negative press and misinformation being shared, so we are still working hard to make sure the right information is available and rebuild the confidence of parents in the programmes.

"We are going through the data and identifying areas where there has been a lower uptake so we need to think about what the barriers are and how we can overcome these. We are engaging families one-by-one and even offering home vaccinations where appropriate. It is time-consuming, but it is worth it."

Contact details

Anne-Marie Gallogly, School Nurse Team Lead, Stockport NHS Foundation Trust: AnneMarie.Gallogly@stockport.nhs.uk

Case study: Walsall - Addressing emotional and mental health problems

Helping children and young people enjoy good emotional health and wellbeing and develop resilience is really important to their overall health and development.

Walsall's school nursing service - delivered by school nurses employed by Walsall Healthcare NHS Trust – provides a wide range of support to children and parents through a programme of group sessions, courses and webinars.

School nurses 'ideally placed to help'

Walsall's school nursing service first started running dedicated emotional and mental health support groups more than 10 years ago.

It started with the FRIENDS programme, which originates in Australia, and is targeted at those struggling with anxiety, low self-esteem and confidence issues. The programme is cognitive behavioural therapy-based and focuses on key skills such as confidence building, problem solving, resilience and communication.

Professional Lead for School Nursing Sallyann Sutton said: "At the time the government was talking about the importance of investing in mental health support, and we knew as school nurses we could play a crucial role. Helping children to look after their emotional health is as important as them looking after their physical health. They need to learn how to cope with the stresses that life undoubtedly throws at them and to bounce back and learn from challenging times."

Over the years, the support has expanded and there are now four dedicated FRIENDS courses:

• Fun FRIENDS for four to six-year-olds
• FRIENDS for Life for seven to 11-year-olds
• Teen FRIENDS for Life for those aged 13+
• Adult Resilience for parents and carers

The courses last between six and eight weeks. The sessions are largely delivered by the service's nursery nurses, but training is available for school staff and partners in children's services, helping to increase awareness and skills among the workforce in the process.

Children work in groups at the sessions, which are run after school in either community venues or the schools themselves – although they were run virtually at times during the pandemic.

Parents need support too

The pre-school and primary school courses involve the parents as well as children, while the 13+ one just involves the teenagers themselves. The parent-focussed one is a more recent addition to the options.

Ms Sutton said: "We found parents were contacting us worried about their children but were themselves struggling to cope. They had low self-esteem and confidence and needed support for themselves. That is why we launched the one for parents. The idea is they start the course so they develop strategies for themselves alongside their children attending groups.

"The support is now needed more than ever. The pandemic has been very difficult, particularly for the more vulnerable families. We are seeing more and more people coming to us for support. Many parents ring us directly needing help.

"We almost do a mini-consultation on the phone before working out what the best course of action is. We can refer on to our local mental health services if need be – there is CAHMS and online counselling available."

"School nurses can take a holistic approach"

But the school nursing service has plenty of ways of supporting families. Alongside the FRIENDS courses, the team also offers a variety of other options. This includes an anger management group for primary-aged children to help them manage their feelings and then there are three parenting courses.

• Understanding Your Child, which is a 10-week course for parents/carers with children under 11 who would like to meet other parents and explore ways to help promote positive behaviour in their child.
• The internationally recognised Triple P parenting course, which focuses on positive parenting and offers different strategies to cope with behavioural problems. Telephone support is also provided.
• A six-week course tailored towards parents/carers who have a child with autism. The Cygnet course combines peer support with tailored sessions based on a programme designed by Barnardo's.

There is also a series of workshops to help parents and carers to understand children's emotions and children's behaviours. These are short sessions which are a good introduction to the service and provide useful tips and hints of strategies that can be tried at home.

They have now been recorded as webinars, but the service is working with Catcher Media to produce a series of more polished films, including podcasts, in line with some of the material that has been produced for classroom-based learning in areas such as sexual health.

Ms Sutton added: "We want to find new ways of engaging parents and children. People consume media like this, and we think it will be a good way of introducing them to what we have to offer before they sign up for the courses. For some, just getting advice and information from these films may be enough.

"But the strength of delivering this kind of support as school nurses is that we can take a really holistic approach if needed. We can do the safeguarding; we can do the healthy lifestyle support. Mental and emotional health problems do not happen in isolation."

Contact details

Sallyann Sutton, Professional Lead for School Nursing, Walsall Healthcare NHS Trust: Sallyann.sutton@walsallhealthcare.nhs.uk

Case study: Derbyshire - Supporting LGBT+ pupils

Derbyshire's school nursing service has invested in extra training for its team to help them better support LGBT+ pupils.

The project has equipped school nurses with the skills and confidence to address the issues these pupils face, helping improve their mental health in the process.

The challenge LGBT+ young people face

Mental health problems, such as depression, self-harm, alcohol and drug abuse and suicidal thoughts can affect anyone, but they are more common among people who are LGBT+.

Being LGBT+ doesn't cause these problems, but some things LGBT+ people go through can affect their mental health, such as discrimination, homophobia or transphobia, social isolation, rejection and difficult experiences of coming out.

A study by Stonewall in 2021 found that over the previous year:

• half of LGBT+ people had experienced depression and three in five had experienced anxiety
• one in eight young people had attempted to end their life
• nearly half of trans people had thought about taking their life

Derbyshire School Nurse Hen Sloman has been instrumental in the work done in the county. Mx Sloman, who is trans, uses both their lived experience and professional knowledge to support the school nursing service run by Derbyshire Community Health Services NHS Foundation Trust.

They said: "It was very clear our LGBT+ pupils needed better support. As school nurses we could see that loud and clear. We have been seeing increasing numbers coming to us with mental health difficulties – young people who are self-harming and even trying to take their own lives. I don't think it is necessarily related to the pandemic, but the last two years have certainly given people more time to think and reflect.

"And we know from the research that has been done that there are long waits for specialist gender services for young people. School nurses though are in a perfect position to support young people. We take a holistic approach. We are trusted and we know the pupils, the schools and the families. We wanted to do more to help," they added.

"Key is gender-affirming care"

The service has worked with Gendered Intelligence, a charity that is focussed on increasing understanding of gender diversity, to run a one-day training course for staff.

Mx Sloman said: "The training was about making our staff aware of how to approach the issue and best support pupils. The key is providing gender-affirming care – not just to trans pupils but to all.

"We start off by asking pronouns and what name they use. That makes a big difference – it basically unlocks that issue from the start and gives the pupil confidence they can talk about gender and sexuality if they want to. I guess it is an extension of the 'My name is…' campaign.

"When you do that, it often doesn't take long for it to surface. The teenage years are crucial, people are exploring their identity. What we have found by just affirming their identity, having someone to talk to who understands and gives them acceptance can really help. We get on to discussing lots of different issues from sleeping problems to family relationships.

"Everyone is different though. We sometimes find that for some pupils they have a handful of sessions with us and that's it. While, for others, they want help from the school nurses to come out to their family or at school. We can support them because of our unique role."

'LGBT+ champions for the whole trust'

As well as providing one-on-one support, the school nurses have also started going into schools to give talks about LGBT+. "We've had schools where pupils have come out as trans and there has been some bullying. We've gone in and explained why that is unacceptable and talked about some of the issues around this.

"It has had a real impact on those year groups. We've also found that pupils have started messaging us via Chat Health off the back of those talks. The more we discuss gender identity, sexuality, and public health the more people we reach. Some pupils are referred to us because it is clear to school staff they are struggling, while for others it is opportunistic – a drop-in session or perhaps when we are discussing another issue. Every contact is a therapeutic opportunity."

The support has been greatly received by the pupils the service has worked with. "My school nurse helped me so much," one young person said. "I wouldn't be where I am now if I hadn't had support. By someone understanding my struggles without me having to explain everything made everything so much better."

And a pastoral leader in one school added: "Our school has been working together with the school nurses to implement positive sexual health relationships including LGBT+ relationships. In addition to educating students about relationships, the school nurses have also worked with us to provide information about gender identity and expression. It has been a huge success and it got the students talking and asking questions. Encouraging our students to broaden their knowledge, educating them, and supporting them."

To help ensure the momentum is maintained, the service has set up a working group of school nurses to monitor emerging practice and the latest research. And this push goes further than just the school nursing team as all 0-19 Healthy Child Programme staff took part in the training with Gendered Intelligence.

Mx Sloman said: "Health visitors were also involved so they can support gender diverse families. The 0-19 workforce are becoming LGBT+ champions for the whole trust, helping influence policy and the way we work. Our priority is supporting all young people at the right time, in the right way whomever they are."

Case study: Leeds - Identifying and supporting young carers

Being a young carer can significantly affect a pupil's education and mental health with little time to do homework, coursework or socialise with friends.

In Leeds routine screening of pupils has begun to identify those who have caring responsibilities and to support them a dedicated pathway has been established to improve links between school nurses and other services.

Why it's important to keep asking

It has become routine for school nurses and health visitors to ask questions about domestic violence in their contact with children and families. But in Leeds this approach has been extended to help identify and support young carers.

Since March 2022 the 0-19 Public Health Integrated Nursing Service (0-19 PHINS) – run by Leeds Community Healthcare NHS Trust – has been routinely asking questions and engaging pupils in conversation to see if they have caring responsibilities at every contact. Where caring responsibilities are identified the nurses carry out a full health needs assessment.

To aid practitioners within the service, two hours of training have been provided to staff. The key question that triggers further investigation if answered yes is: "Some people your age provide help or support to people who are physically or mentally ill, disabled or misusing drugs or alcohol. This could be a parent, brother, sister, another relative or someone else. Is there anyone who you have to look after on an ongoing basis? This could include people who you live with and people who you do not."

Amanda Jackson, one of the Clinical Team Managers for 0-19 PHINS, said: "We have always asked about caring responsibilities, but what is different about this approach is that it is done at each and every contact and there is a now a systematic approach to it.

"The issue for young carers is that not everyone recognises they have caring responsibilities or have only recently developed caring responsibilities so by asking about it we are raising awareness and helping people recognise when they have caring responsibilities.

"Caring responsibilities change over time – parents may have suffered a sudden illness or injury for example. That has been particularly the case during the pandemic so that is why it is important to keep asking."

We can help find solutions

Mrs Jackson said the new way of working was already having an impact. "We are identifying more carers, but quite often they don't know what support is available to help them or are just trying to manage on their own.

"For example, in one recent case study discussed in the training, a child was arriving half-an-hour late to school every day because they needed to help their mum with medication she needed to take at 9am.

"The school were happy to accommodate it, but that child was missing two-and-a-half hours of school every week. That would have soon started to have an impact.

"The multi-disciplinary team around the child were able to talk to the pharmacy about getting the mother a dosette box, which indicates when each medication needs to be taken. It meant she could take more responsibility for taking the medication and the child could get to school on time.

"Sometimes there are relatively simple solutions to help young carers, but even when it is more complex, and our 0-19 Specialist Public Health Nurses are well connected to find a way forward."

As part of an initiative 0-19 PHINS has developed a pathway with local organisations that can provide support. The key service is Family Action Leeds, which is commissioned by the council to provide support to young carers. It has a support group for young carers and can arrange extra support so young carers can have more freedom if they want it.

There is also an app that has been developed and is used regionally for young carers.

"We find most young carers want to continue providing care, but sometimes it is about just unlocking a little time for the young person – maybe allowing them to do an after-school club or activity," added Mrs Jackson.

Part of a wider push to better support families

It is not just school nurses who are working to identify hidden and new young carers though. Health visitors also ask the parents they come into contact with whether anyone in the family has caring responsibilities.

It is part of a wider push to better identify and support those families that need help. As well as the young carers pathway, there is also one for the youth justice system to identify those at risk of becoming involved in criminality.

Again, there are a range of organisations school nurses can involve, including the youth offending team and Getaway Girls, a local charity that works to empower girls

Each pupil identified as in need is given a named school nurse to work with although for the most complex cases there are what are known as differing fields practitioners. These are specialist community public health nurses who have been trained as both health visitors and school nurses to provide a holistic range of support across the age range. The service has a number of these in place and are committed to continuing the opportunity for more nurses to complete the differing fields module.

Mrs Jackson added: "The 0-19 service is ideally placed for this work. Our staff are trusted and are linked in with services. It is helping us better support young people and families."

Contact details

Amanda Jackson, 0-19 Clinical Team Manager, Leeds Community Healthcare NHS Trust: amanda.jackson1@nhs.net

Case study: Northumberland and North Tyneside - Supporting children with special educational needs and disabilities

A dedicated school nursing service has been set up in Northumberland and North Tyneside to support SEND schools. The team provides on-site nursing provision to seven schools across the area to pupils with specialist health needs.

'Every child deserves support from a school nurse'

There is no standard approach to providing nursing support to SEND schools. In some areas there are specialist services commissioned solely by the NHS, sometimes in partnership with the council. But in other areas, it is the core school nursing or children's community nursing service that provide this support.

In Northumberland and North Tyneside, the two CCGs commission Northumbria Healthcare NHS Foundation Trust to provide a dedicated special school nursing service. The trust provides an on-site service at seven schools that educate children and young people with profound physical and learning disabilities. Outreach support is also provided to other schools with more moderate needs.

Service Team Leader Elaine Davies said: "All children deserve access to the Healthy Child Programme – and that is what our service ensures and more thanks to the investment made in Northumberland and North Tyneside. But sadly, this is not the case everywhere."

The nurses, many of whom have a background as specialist community nurses, support children and young people in the schools with their specialist health needs, which include physical and learning disabilities, tube feeding, respiratory issues, diabetes, continence and complex epilepsy. The team also provides emotional and behavioural support, health education and promotion, training to school staff, such as on tube feeding, and assessment and care planning.

"It has been particularly challenging during the pandemic," said Ms Davies. "Many of the children were shielding and families were very concerned about COVID. Attendance has now returned to normal.

"We provided fit testing for education staff to be fitted with the correct PPE for aerosol generating procedures and we supported schools with testing. We proactively worked with families about the individual needs of children, to support their health needs during the pandemic, and for them to safely attend school.''

"Children missed a lot of schooling, and we are beginning to see some of the fallout from the pandemic – children with mental health needs and anxiety and family breakdowns. For some it is manifesting itself in escalation in behavioural issues and exploitation. We work with children's social care, CAHMS and the community learning disability team who have access to psychologists and specialist services to support these children."

How the team makes a difference

Alongside this, there is also bespoke support available for those at different stages of their school life, including for those transitioning to adulthood as well as young children just starting school. Thanks to new investment pupils starting nursery and primary school are now offered health needs assessments by the nurses as soon as their school place is confirmed. Bespoke support for the family, training for education staff and care planning is then put in place in advance to allow the child to start school with all preparations in place as soon as the term begins.

Ms Davies said: "We were finding that for some children the start of school was problematic - this is helping to alleviate that. Families and schools are greatly appreciating this enhanced support."

The support put in place is making a huge difference to individual families. For example, the school nurses recently helped an 11-year-old girl who had become anxious and upset about a planned operation she was due to have for bladder and stoma surgery. She was getting so upset in lessons that she had to be sent home and was missing school.

The nursing team started to meet with her every week in the lead up to her surgery, talking about what the operation would involve and how feeling different emotions was only natural. They also watched age-appropriate videos of the surgery with her, helping her to understand the procedure. She became more settled and was able to stay in lessons and concentrate on school again.

In another case a child with a range of learning disabilities, including cerebral palsy, had developed problematic dry skin. It transpired that she was struggling to have a regular full body wash because an adapted bathroom had not been completed at her home because of COVID restrictions. After discussions with her family, the school nurses worked with the community nursing team to arrange a carer to help her shower at her school's adapted bathroom.

Ms Davies said examples such as these that illustrate the importance of supporting these vulnerable children. "By working closely and having the expertise, a dedicated school nursing team can have a major impact on children with special education needs and disabilities, helping to keep them in school and healthy and well."

Contact details

Elaine Davies, Team Leader, Special School Nursing Service, North Tyneside and Northumberland: Elaine.Davies2@northumbria-healthcare.nhs.uk

Case study: Warwickshire - Encouraging healthy lifestyle

Warwickshire has a school health and wellbeing service which incorporates school nurses and a healthy lifestyle team. Between them they take a holistic approach to supporting children and their families to eat healthily and exercising regularly.

After-school healthy lifestyle clubs

The school health and wellbeing service, called Connect for Health, is run by Compass. Alongside the school nurses there is a range of skill mixes, including a five-strong Change Makers team, which runs a healthy weight management programme.

Children identified as being overweight through the National Child Measurement Programme or by school nurses as part of their everyday work and health assessments are offered places on the seven-week Change Makers programme.

The programme involves a series of after-school clubs for children and their families. The clubs cover a wide range of topics from portion sizes and food labelling to meal planning and live cooking sessions. Participants also get to take part in fun activities and games, such as dance and rounders.

Families are given activity booklets providing them with tips about how to maintain a healthy lifestyle alongside fun activities, such as a food alphabet challenge. For families with more complex needs, one-to-one support from the Change Makers team is available.

"The course was a real eye-opener"

The families that have taken part in the workshops say they have had a significant impact on their lives. One mother whose son took part said: "I am really enjoying the sessions and felt very supported, and it has been such a good experience. Each week we have made a positive change and my son has felt so much better too. He is not raiding the cupboards anymore. The whole process has been so positive, even on my mental health as I struggle with this."

Another parent added: "The course was a real eye-opener. They gave us some really great tips and amazing ideas to move forward."

Follow-up evaluation has also shown positive results. Twelve months after completion of the programme fruit and vegetable intake is at six a day on average, above the recommended levels, and participants are completing 60 minutes of activity a day, up from 15 at the start of the programme.

"It really makes a difference to families," said Service Assistant Director Maggie Clarke. "What is great is because we are all part of the same team, we are promoting healthy lifestyles in a consistent way and when we spot someone who needs help, we can quickly get them into one of the programmes.

"Families can, if they want, pick and choose workshops they go to, but we find most enjoy and value it so much that they want to go to them all.

"The problem with something like this is that families can become very suspicious of such interventions, but because of the trust we have as school nurses and the excellent way the Change Makers team works, we do get good uptake.

"But we are always looking at ways we can improve. At the moment we are consulting with families to see what we can do differently. We are beginning to think about running sessions in community venues and taking it out of schools more. That could help reach out to those who do not currently engage."

Making the most of the outdoors

Alongside the Change Makers course, the school health and wellbeing service has also partnered with The Warwickshire Wildlife Trust to produce a booklet encouraging people to get active and make full use of the trust's 67 nature reserves.

The extensive network of green spaces means no resident is more than six miles from a reserve. Ms Clarke said: "There are some really wonderful places so we have produced a booklet setting out where families can go and what they can do. It was something we decided to do during the first year of the pandemic as people were really restricted and there was a big encouragement to make more of outdoor activities."

The booklet, which was launched last summer, includes a wide range of ideas for activities from mini-beast hunting and leaf races to scavenger hunts and smelly potion making. It has been used by thousands of people. And this year the trust and school health and wellbeing service have started promoting a den-building challenge, encouraging children to use sticks and twigs to build dens.

Ms Clarke said: "We are constantly looking for ideas to get people active and healthy. We do a lot of promotion on social media. In fact, every day we try to put out a message on Instagram – things such as interesting ways to get fibre into your diet, using your garden as route to mindfulness or getting out on a family bike ride.

"Getting people active, eating well and sleeping well is of huge importance to both your physical and mental health so as school nurses we feel passionately about doing everything we can to encourage this among children and their families."

Contact details

Maggie Clarke, Service Assistant Director, Connect for Health Compass: maggie.clarke@compass-uk.org

Case study: Northamptonshire - Making sure home educated pupils get support

Northamptonshire's countywide school nursing service has set up a dedicated pathway to ensure home educated children do not fall through the gaps. All electively home educated pupils are contacted by the service – with those identified as most in needed offered appointments.

How the pathway works

The pandemic has meant there has been a rise in the number of electively home educated pupils. Estimates from the Association of Directors of Children's Services suggest the figures may have jumped by as much as a third nationally. Home education however can mean pupils miss out on the opportunity of regular contact with school nursing services.

But in Northamptonshire that is not the case because of a home education pathway that was introduced back in 2017. The school nursing service for North and West Northamptonshire councils, which is delivered by Northamptonshire Healthcare NHS Foundation Trust, is specifically commissioned to provide support to all pupils resident in the county, not just those in school.

NHFT 0-19 Public Health Matron Pippa Gilbert, said: "We believe that all children, young people and families should have direct access into the school nursing service to support early intervention, prevent health problems developing and tackle some of the inequalities which impact health.

"Home educated children and families can miss out on the service as it is largely delivered in partnership with schools. We have always been there for them, but in the past much depended on whether we were aware of them or if they came forward for our help.

"Under this arrangement we have an agreement in place with North and West Northamptonshire councils that every autumn they will send us a list of the home educated pupils. Our administrators and school nurse assistants then input that information into our system, and we start the process of reviewing each child and family."

All parents – or a young person themselves if over 16 – receive a letter informing them of the school nursing service and with contact details, including the Chat Health text number which enables them to speak to a school nurse via a secure text messaging service.

The service also assesses families on the voluntary home educated register for those considered at risk. This is carried out through a review of the health record, which alerts the service when children have been in contact with services such as social care, early help, been exposed to domestic abuse or safeguarding or exploitation concerns have been raised.

NHFT Public Health Matron Sue Stevens, who is the safeguarding lead for the service, added: "When this happens, we send them a letter inviting them to come in for an appointment. We book the appointment for a set time and place to try to encourage them to engage.

"If they do not come, that flags up as a non-attender and we either follow the family up with a phone call or home visit or alert other services."

The full range of support

Home educated children can get access to the full range of school nurse services from immunisations and health assessments to advice and information.

Appointments can be booked at a local community clinic or nurses will visit the child's home if necessary. These services are provided by all the county's 45 school nurses.

Before the pandemic there were regularly 800 to 900 pupils on the voluntary home educated register but that has now increased to over 1,500. "There are a variety of reasons why parents choose to home educate," continues Ms Gilbert.

"The pandemic has certainly been a big factor and increased the numbers. We do find some choose to home educate for a short period, but the important thing is that we now have a firm understanding of who is home educated and we can make sure we provide them with access to the full range of services and support."

Dealing with anxiety-based school avoidance

As well as home education, the service works hard to provide help to those who refuse to go to school – known as anxiety-based school avoidance.

Ms Gilbert said: "Schools and other agencies let us know when a pupil is not attending school and we then follow that up often with a home visit. Sometimes these pupils have additional needs – autism, ADHD or dyslexia and we sometimes refer on to the local specialist services that offer assessment or advice and support in relation to special educational needs and disabilities."

The support is proving invaluable to pupils. One of those who has been helped is 15-year-old Jess (not her real name). She has been home educated for the past two years after getting bullied at school.

During contacts with Jess the school nurse identified she struggled when there were changes in routine or social situations, prompting her to be visibly upset, covering her ears and shouting. She also had a disrupted sleep pattern and had become isolated from her friends.

The school nurse meets regularly with Jess for walk-and-talk sessions to help her manage her anxieties and sleep and she has also helped refer her to a specialist team for an autism spectrum disorder assessment.

In another case 13-year-old Lucy (not her real name) was redirected to the school nursing service following a CAMHS referral. The school nurse established a relationship with her mother via telephone and after several phone calls she eventually agreed the school nurse could visit their home.

There was evidence of hoarding in the property and the mother explained her daughter had learning difficulties and literacy issues. She has also been referred for an ASD assessment and the school nurse has arranged support for the mother from partner agencies as well as continuing to support Lucy, who is now going to school for two hours a day after two years without going.

Contact details

Pippa Gilbert, 0-19 Public Health Matron, Northamptonshire Healthcare NHS Foundation Trust: Pippa.gilbert@nhft.nhs.uk

References

dennisonhazinge.blogspot.com

Source: https://www.local.gov.uk/publications/school-nursing-looking-after-health-and-wellbeing-school-children

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