Abstract
The care of children and young people is an important part of the role of the GP. As well as promoting the health of children and young people during contacts, GPs may refer children and their families to other health professionals for targeted interventions. Over the past few years, there has been considerable research concerned with the health of children and young people and policy drivers emphasizing a multi-agency approach. Most recently, the government has introduced ‘The Healthy Child Programme 0–19 years' (HCP) which provides further guidance on the commissioning of children's services. This article sets out to provide a greater understanding of the HCP (5–19 years) and the role of the school nurse within the school health team. This insight will assist GPs in understanding how best to support the unique needs of children and young people and the families who care for them as required in the GP curriculum.
The GP curriculum and children and young people
Demonstrate an understanding of the importance of multi-agency working
Coordinate care with other primary care professionals, paediatricians and other appropriate specialists, leading to effective and appropriate care provision, taking an advocacy position for the patient or family when needed
Deal effectively with the abuse of children and young people, safeguarding children and young people
Describe the principles of clinical governance and risk management
Ensure that parents or carers, children and young people receive information, advice and support to enable them to manage minor illnesses themselves
Prescribe and advise appropriately about the use of medicines in children and young people
Demonstrate an understanding of the welfare of the unborn baby
Manage primary contact with children and their families—and, with older children, on their own
The HCP is divided into two parts: 0–5 years: pregnancy and the first 5 years of life and 5–19 years [Department of Health (DH), 2009)], which extends the universal progressive model of child development into later childhood and adolescence. Found on the DH website, the HCP document provides a good practice framework for prevention and early intervention services for children and young people. It is an evidence-based ‘gold standard’ of recommendations rather than mandatory requirements, aimed at promoting optimal health and well-being for children and young people.
The HCP is founded in the five outcomes identified in Every child matters (ECM) (DH/Department for Education Skills, 2004). ECM outlined national and local priorities and is a set of reforms supported by the Children Act (HM Government The Children Act, 2004).
The White Paper outlined a child-centred approach to health and social care and the Children's Act provides a legal framework to enable information sharing between practitioners for the benefit young people and their families. The United Nations Convention on the rights of the child advocated in 1989 that children should be involved in decisions about their lives and in the UK, this is now an accepted approach in the delivery of health and social care (Gelling, 2007).
The aim of ECM is for every child, whatever their background or circumstances, to have the support they need to:
be healthy
stay safe
enjoy and achieve
make a positive contribution
achieve economic well-being
School nurses make a significant contribution to the achievement of all these outcomes. ECM (DH/DfES, 2004) also recognized the importance of supporting parents, carers and families in achieving the best outcomes for children and young people.
Emphasis upon early intervention and prevention
The HCP presents the case for prevention and early intervention and provides evidence-based illustrations. For example, an obesity study by Foresight (2007) predicts that weight-related problems are forecast to cost £50 billion to the wider economy by 2050. As Michael Marmot, the chair of the Strategic Review of Health Inequalities in England post 2010 surmised, a ‘focus on prevention and early intervention has a vital role in breaking the cycle of health inequalities within families and action taken to reduce health inequalities will benefit society in many ways’ (Marmot, 2010).
The HCP guidance is aimed at those planning and commissioning the services for the health and well-being of 0- to 19-year-olds and the health and non-health professionals delivering the HCP. The guidance recommends a full range of interventions to support children, young people and their families. It includes a schedule of universal and progressive services divided into age bands, with an emphasis on seamless transitions between stages. Examples of transitional stages include pre-school to school age, leaving primary education and beginning secondary and leaving school for work or further education. Different areas of the country will adapt the HCP depending on the local needs of their population.
The school nurse
It is well established that good physical and mental health has a positive impact on learning and achievement (DH, 2009). Poor health may lead to low attendance at school, affecting academic achievement and subsequent employment opportunities. School nurses at the core of the school health team are perfectly placed to contribute to the health and well-being of children and young people (DH, 2009). The HCP illustrates a commitment to ensure all schools have access to school nursing expertise. Chase et al. (2010) published an independent report looking at the role of the nurse in schools and perception of school nursing found that school nurses ‘are highly valued when pupils, staff and parents are aware of who they are and what they do’.
The study also found that school nurses' clinical knowledge and the confidentiality of their service are particularly valued by children and young people. Young people also valued the involvement of nurses in sex relationship education (SRE) and personal, social and health education (PSHE) sessions in schools and often preferred discussing sensitive issues with a nurse rather than a teacher.
The DH is currently working with school nurses developing a school nursing service model for England. The health visitor implementation plan 2011–15 was completed in January 2011. Public Health Minister Anne Milton has recently said ‘All the evidence indicates that the early years play a significant role in shaping your health, wealth and happiness for the rest of your life’. Evidence detailed in the Solihull Approach demonstrates that the teenage years also play a significant part in shaping health due to the crucial brain development that takes place during this time (Solihull NHS Primary Care Trust, 1996). Magnetic resonance imagingbased research carried out by neuroscientists such as Baird (1999) and Giedd et al. (1999) supports the theory that an adolescent's brain is still developing, particularly in the frontal lobe and therefore structurally different to the adult brain. This slow maturity of the cognitive control system predisposes ‘risky’ and ‘thrill-seeking’ behaviour.
Specialist Community Public Health Nurse qualification
Like a health visitor, a school nurse within the National Health Service (NHS), will have the specialist qualification Specialist Community Public Health Nurse (SCPHN). As part of their specialist training, school nurses have developed their leadership skills in order to work more effectively in partnership with other agencies. The document by DH (2006a) Looking for a school nurse? explains the key responsibilities of a school nurse as being:
To assess, protect and promote the health and well-being of school-aged children and young people
• Advise, care and treat individuals and groups of children and young people and the adults who care for them
Research in the UK over the past few years has highlighted widespread concern about a range of health issues for children and young people, including the rising prevalence of mental health problems (Tylee et al., 2007), increasing levels of obesity (Foresight, 2007), high numbers of unplanned pregnancies (Larsson et al., 2006) and rising rates of sexually transmitted infections (STIs) (Parliamentary Office of Science and Technology, 2004).
The School Nurse: Practice Development Resource Pack (2006b) lists the health priorities for school nursing (Box 1). The HCP largely mirrors this and the services recommended by the Resource Pack.
Health priorities for school nursing.
Prevention of accidents
Alcohol and drugs
Smoking cessation
Mental health and psychological well-being
Nutrition, childhood obesity and physical activity
Safeguarding and promoting the welfare of children
Sexual health, teenage pregnancy and teenage parenthood
Personal, social and health education
School nurses can work with young people, schools and parents in a number of ways. For example, by participating in the delivery of school-based prevention programmes, delivering PSHE sessions, running support groups for parents and targeting vulnerable and deprived groups. Areas will vary, but examples of PSHE sessions facilitated by school nurses may include ‘Safe Medicines’ and ‘Hand washing’ for Key Stages 1 and 2. Secondary schools may request their school nurse support the PSHE programme by delivering sessions to pupils about STIs or contraception. School nurses can also tailor sessions according to a particular health need such as ‘Healthy eating versus dieting’ or ‘Dealing with exam stress’. School staff (teaching and non-teaching) must also access regular training in the management of conditions, such as asthma and anaphylaxis. This facilitation is usually carried out by the school nurse. (See Case Study 1).
Case Study 1
Mrs Thomas mentioned during her own appointment that her anxiety symptoms had considerably increased as her son, John, was about to start school. Although she was looking forward to this next stage in her son's life, his severe asthma and the school's ability to manage this were worrying her. Her son's previous nursery had not been confident with regards to managing his medication and the high dosages required compared to other children meant that they asked her to administer the medication. This was not going to be practical once the child was going to be at school all day and Mrs Thomas was also hoping to return to work.
The GP explained that the care of John's health needs were handed over from the health visitor to the school nurse during the transition to school and provided his patient with details of the school nurse. The GP suggested that the school nurse would be able to work with the school to compile the child's care plan.
During her next consultation, the patient reported to the GP that she had been visited at home by the school nurse and had discussed her son's health needs at length. An appointment had been made with the school to discuss her son's care plan. Furthermore, the school nurse has arranged to attend the school and provide additional asthma management training for all the staff at the school. Mrs Thomas' anxiety symptoms had also improved.
School nurses are also in the unique position of being able to see children in school on a one-to-one basis, with parental consent if they are too young to be Fraser competent. This enables the child to complete Tier 1 level emotional health work with the school nurse on topics such as improving self-esteem or dealing with parental separation and divorce. Furthermore, school nurses can, where necessary, refer on to other services, such as the child and adolescent mental health service (CAMHS) or a young carers project. Helping children and young people to develop emotional resilience is essential to their success in adult life.
In addition to this, and with a skills mix team that includes nursery nurses and staff nurses, school nurses conduct a reception year health assessment, reviewing health needs and measuring children's height, weight, vision and hearing screening. A health review during the transition years from primary to secondary school offers the opportunity to gather health information and allow parents the opportunity to raise concerns, identify incipient mental health problems (such as disordered eating) and examine the child's body mass index (BMI) to explain diet and lifestyle.
Safeguarding
Everyone working with children has a responsibility to safeguard and promote their welfare. Detailed procedural guidance can be found in the ‘Working together to Safeguard Children’ (HM Government/DCSF, 2010) inter-agency guide. Child protection lead nurses also advise and support nurses who work with children and offer guidance on report writing for conference as well as clinical supervision. The UK charity the National Society for the Prevention of Cruelty to Children (NSPCC) reports that as of 31 March 2010, there were 46 705 children on child protection registers or the subject of child protection plans in the UK (NSPCC, 2010). School nurses can provide parenting support to improve parental capacity to respond to their child's needs. School nurses can also signpost and action referral to services, such as the Freedom programme, a rolling programme providing information about male violence against women.
School nurses can work with schools and other agencies to complete Common Assessment Framework referrals (CAFs) and participate in Team Around the Child meetings (TACs). The CAF is an early intervention tool designed to assist with the joint planning and commissioning process enabling the right service to reach the right child at the right time (Rees and Morley, 2007). Effective inter-agency working ensures regular communication through regular meetings (TACs) enabling agencies to work together and share information in order to reduce duplication of effort. Schools can instigate the CAF process and are encouraged to inform their school nurse even if there are no obvious health needs from the outset. Coordination and communication with a school nurse may reveal that a GP's patient is already subject to the TAC process and a number of agencies are already involved and supporting the family (see Case Study 2).
Case Study 2
During a consultation about their 8-year-old daughter's dry skin, Mr and Mrs Long had expressed concerns about their daughter's disruptive behaviour and their inability to manage it. Their daughter was refusing to go to bed and running away outside the house when challenged. Both parents have learning disabilities and a history of mental health problems. The GP decided a referral to CAMHS would be appropriate and dictated a letter.
Following the day's surgery, a look back in the notes revealed a copy of a letter received from the Early Intervention Team 6 months earlier informing the GP that the TAC process was going to begin taking place following the school nurse's referral. A conversation with the school nurse, who was also based in the surgery, revealed that the nursery nurse was regularly visiting the family home offering behaviour management strategies.
In addition to this, the child had refused to engage with the staff nurse working in the school nurse team during school time to undertake Tier 1 work. It had been agreed with the school that it was not appropriate to take the child out of lessons as she was already behind with her work. She was also being seen by a Speech and Language therapist, the Educational Psychologist and received additional support due to her educational statement.
To support the parents, the school nurse was currently referring the child to Young Carers' organisation. The school nurse had also discussed this case with CAMHS on their consultation line. It was agreed that a referral was not appropriate at this time due to the child's unwillingness to engage in Tier 1 work with the school nurse and as a number of other agencies were already seeing the child.
Concerns about the safeguarding of a child should be referred to social care but a school nurse may provide a useful source of support and guidance for the GP as their role involves regular participation in case conferences and core groups as well as working with other agencies towards the fulfilment of criteria set out on a child protection plan.
Contraception
The Department of Health's ‘You're welcome’ (DH, 2007) quality criteria stipulate that all young people should have easy access to confidential contraception and sexual health advice. This should be delivered by staff that are well trained and can offer guidance and advice. In many areas of the country, there is a C-card programme, which is a condom distribution scheme that young people under 25 years can sign up to, helping to protect them against unwanted pregnancies and STIs.
On signing up to the scheme, free condoms are given out following advice to help young people stay safe. Information on STIs, pregnancy and contraception are given during this contact and young people can also discuss relationships, in confidence, with trained professionals.
The 2007 ‘You're welcome’ criteria also outline that chlamydia services should be integrated with contraception and sexual health services. Under 25s should be encouraged to be screened annually for chlamydia or whenever they have a change in partner.
The expected outcomes of the HCP are better accessible health services and improved experiences for children, young people and their families. Improved data collection and analysis will also be invaluable to guide and inform needs-led commissioning and service provision. Recognition of the school nurse and the role will also be beneficial when commissioning services and ensuring adequate posts are funded to support the school-age population. An understanding of the role of the school nurse and the Healthy Child Programme by GPs and other health professionals will also enable more effective multi-agency working and will greatly benefit children and young people.
Key points
Over the past few years, there has been considerable research concerned about the health of children and young people and policy drivers emphasizing early intervention and prevention with a multi-agency approach to promoting the health and well-being of children and young people
The Healthy Child Programme is divided into two parts: 0–5 years: pregnancy and the first 5 years of life and 5–19 years, which extends the universal progressive model of child development into later childhood and adolescence
The role of the nurse in schools and perception of school nursing found that school nurses ‘are highly valued when pupils, staff and parents are aware of who they are and what they do’
The DH is currently working with school nurses developing a school nursing service model for England