Refocused school nurse role: early adopter evaluation summary

5. Findings

5.1 Overview of Referrals from November 2015 to end of May 2016

The two early adopter sites had received different numbers of referrals from November 2015 up till May 2016. D&G recorded 299 children and young people who had been seen by the School Nurse service. P&K recorded 107 for the same period. However, the team in P&K had had to continue with their immunisation work in schools in addition to adopting the new role.

Gender

In both areas more girls were referred into the School Nurse services than boys, although a slightly higher percentage of girls were seen in D&G than P&K.

Table 3: Numbers and percent of children seen by School Nurse by gender

	Perth and Kinross (n=107)	Dumfries and Galloway (n=299)
Female	53.3%	63.7%
Male	46.7%	36.3%
	100%	100%

Age/Year Group

Overall a higher proportion of secondary school children were referred into the School Nurse service in D&G than in P&K who had a higher proportion of primary school children referred in.

Table 4: Percent of children seen by School Nurse by Year Group

	Perth and Kinross (%)	Dumfries and Galloway (%)
Nursery	2	0
P1	14	6
P2	14	4
P3	12	2
P4	7	7
P5	4	2
P6	4	3
P7	4	4
S1	4	9
S2	10	16
S3	8	14
S4	12	18
S5	3	12
S6	1	3
Total	101%	100%

SIMD

P&K appear to have had a lower proportion of children from SIMD quintiles 1 and 2 referred into the School Nurse service than D&G. However it should be noted that there were a high number of children in D&G where the postcode had not been fully reported and so it was not possible to ascertain in which quintile they resided. In addition, both D&G and P&K have a higher proportion of children living in quintiles 4 and 5 than the national average so a higher number of referrals from these groups would be expected for these areas. However, as can be seen from the table, a higher proportion of the children from the more deprived SIMD quintiles were referred to the SN.

Table 5: Percent of Children referred to School Nurse by SIMD - Perth and Kinross

	Perth and Kinross
	No. children referred to SN	% of total referrals to SN	Population of SIMD aged 5-19 in P&K	% of SIMD population 5-19 referred to SN
SIMD 1 (most deprived)	11	11%	1355	0.8%
SIMD 2	23	23%	2550	0.9%
SIMD 3	19	19%	5060	0.4%
SIMD 4	35	35%	10357	0.3%
SIMD 5 (least deprived)	13	12%	4833	0.3%
Total	101	100%	24,155	0.4%
No postcode given	6	6%

Note: The populations used to derive the proportions are weighted according to ISD weighting schedule.

Table 6: Percent of Children referred to School Nurse by SIMD - Dumfries and Galloway

	Dumfries and Galloway
	No. children referred to SN	% of total referrals to SN	Population of SIMD aged 5-19 in D&G	% of SIMD population 5-19 referred to SN
SIMD 1 (most deprived)	56	26%	2243	2.5%
SIMD 2	45	21%	6135	0.7%
SIMD 3	73	34%	8884	0.9%
SIMD 4	34	16%	3919	0.9%
SIMD 5 (least deprived)	6	3%	2076	0.3%
Total	214	100%	23,257	0.9%
No postcode given	84	28%

Note: The populations used to derive the proportions are weighted according to ISD weighting schedule.

Children's Status on and after Referral to School Nurse

On the whole HPI status was not an accurate predictor of the need for referral. Both areas took referrals from children on Core and Additional HPIs although P&K had fewer children referred on additional HPIs than D&G. This is despite proportionately more children from primary school being seen by the P&K nurses.

Table 7: Percent of Children by HPI status on referral

	Perth and Kinross	Dumfries and Galloway
Additional	21	77
Core	69	16
Pending	4
Unknown	7	7

A certain proportion of children also were referred in because they were subject to a Child's Plan, they were on the Child Protection register or they were Looked After (often in kinship care). However, the figures below also refer to children's status after intervention by the School Nurse, so they represent children who had a Child's Plan in place on referral plus those who were assigned a plan as a result of being referred to the School Nurse.

Table 8: Percent children referred to School Nurse by status

	Perth and Kinross	Dumfries and Galloway
Child's Plan (after SN intervention)	24	29
Child Protection	1	6
LAC	3	15

Note: The three columns represent separate groups of children although any one child could be LAC, on the Child Protection Register and have a Child's Plan in place.

5.2 Main themes from the Evaluation

Programme Implementation and the Nine Priority Areas (Pathways)

It was felt the nine priority areas and pathways provided a clear framework which ensured only the relevant cases were referred to the School Nurse. However concern was expressed that there were some gaps in the priority areas, such as sexual health and physical health (eg obesity and enuresis) which were not covered.

Some pathways were used far more than others with Mental Health and Well Being being widely used and pathways such as those for homelessness and Youth Justice being very little used. This may be because these early adopter areas experienced lower levels of child/young person homelessness and involvement in the youth justice system than is prevalent nationally. However, it was felt by the SNs that the Mental Health and Well Being pathway was sometimes used as a 'catch all' for occasions when there did not seem to be an appropriate pathway.

Whilst many of the pathways were seen as providing useful guidance, other pathways, in particular the Mental Health and Well-being and Substance Abuse were seen as needing further development.

According to the records, the majority of children were referred in to the service for mental health and well-being issues. As can be seen, 68% of those from both P&K and D&G were referred in to the service because of concerns around a child's mental health and well-being. There was quite limited representation on the other pathways, except those children who were Looked After in D&G. It should be noted, however, that a high proportion of children in P&K had not been referred into the service on any particular pathway.

Dumfries and Galloway also reported on the pathways children were assigned to after meeting with the School Nurse, when School Nurses might change the pathway following more in-depth assessment. In this case some 50.5% of children were not given a pathway presumably because the referral had been declined or the children had received one episode of care before being discharged.

Table 9: Percent of Children on Pathways at Referral and after SN intervention

	Perth and Kinross	Dumfries and Galloway
		Before SN intervention	After SN intervention
Mental Health and Well-Being	68	68	37
Substance Misuse	0	0.3
Child Protection	0	4	3.3
Domestic Abuse	3	2	2
Looked After Children	0	12	8.4
Homelessness	5	1	0
Youth Justice	3	0	0.3
Young Carers	5	0.3	2.7
Transitions	0	4	2.7
Unknown/Discharged	32	9	50.5

Please note: children could be on more than one pathway, hence the percentage add up to more than 100%

Referral

Both D&G and P&K developed new referral systems. These took some time to embed and referrals were slow at the start of the pilot. In addition IT issues affected whether referrals could be made electronically or not. However, referrals have increased over the period and the demand for specificity around the needs of the child/young person means that School Nurses felt that more thought was being given to referrals. This also helped clarify the role of the School Nurse.

As can be seen from the table below, school was the main source of referral, particularly in P&K but Social Work, other health services and other agencies also referred.

Table 10: Percent of Children referred to School Nurse Service by referrer

	Perth and Kinross	Dumfries and Galloway
Health Services incl GPs, HVs and A&E, CAMHS	7	6
School	92	68
Parent	1	3
Self referral	1	1
Other eg LAC, Child Plan Meeting, SACRO	0	4
Social Work	0	11
Missing	0	8

In terms of referrals that were declined by the School Nurse team there was some variation between the two areas. School Nurses in P&K declined nearly 20% of the referrals to them, 65% were accepted and data is missing on the remaining 16%. In D&G only 5% of referrals were declined. However, there were many cases where the School Nurse had only seen the child once suggesting that the School Nurse was in some cases declining the referrals after making their own assessment.

Table 11: Reasons for Declining Referral (numbers)

	Perth and Kinross (N)	Dumfries and Galloway (N)
Already being seen by another professional (health or other)	9	2
Parent refused	1	1
Referral did not fit criteria	1	2
School Nurse felt another service was more appropriate	6
Child did not attend	2
Inadequate Information was given	1
Child did not want support	1

There is confusion as to whether referrals are in fact referrals or are 'Requests for Assistance' under the 2014 Children's Act. This needs to be clarified at national level. There is also some confusion as to the role of the HPI status of the child. In one area all children with an Additional HPI were placed on the School Nurses' caseload. In another area the School Nurses' caseload comprised only those children referred in regardless of HPI status.

Role Clarity and Standardisation

The intention was that several school nurses' duties would be discontinued to create additional capacity for implementing the nine priority areas. However, this was not always possible and in P&K, in particular, School Nurses had to continue to undertake immunisations. This meant that they could not fully implement the refocused role. In D&G a team had been created specifically to undertake immunisations from the SN budget and this appeared to work better.

Whilst the refocused role had been designed in some detail and School Nurses knew what was expected from them there was some lack of clarity as to the role of members of the wider team.

School Nurses broadly welcomed the more clearly defined role in terms of validation for their work and clear lines of responsibility when engaging with other services. However some nurses felt that the new role was not for them and several staff resigned, were re-deployed or retired during the course of the early adoption.

Due to shortage of staff therefore, Band 5 nurses were employed during the pilot with a view to training them up to undertake the refocused School Nurse role, but delays in implementing the training courses and the temporary nature of their contracts meant that the first round of recruited nurses left for other posts. Additional Band 5 nurses have since been recruited with a view to them being trained up as fully qualified School Nurses.

Engagement and Accessibility

It was perceived that the diversity of the priority areas facilitated engagement with partner agencies in a more positive way. This has also meant that School Nurses' visibility to other agencies had improved. Both areas developed Steering Groups which brought partners together and this was seen as a useful way of engaging partners. The refocused role has meant that School Nurses are having more engagement with certain agencies for example, Youth Justice than previously and this is regarded as a positive development.

In addition staff at the schools understood the role of the School Nurse better. However, the refocused role has meant that School Nurses are less visible to children and young people in the schools. Increased home visits has meant that some families are more aware of their role but many children may not meet the School Nurse unless referred. There was some concern that because School Nurses were less visible in the schools, children and young people, especially those who did not wish to go through Pupil Support, were not able to access the service. D&G have suggested overcoming this by utilizing a text message service where children can directly access school nurses, but this may require careful evaluation.

Training and Support

In P&K only one School Nurse out of 13 held a Specialist Public Health Qualification ( SPQ) and in D&G four out of the nine School Nurses held SPQs and one member of staff held a Certificate in School Nursing.

It was recognized that adoption of the nine priority areas would also mean additional training was necessary, over and above that contained in the SPQ. Masters level modules were therefore developed by three Higher Education Institutes (Robert Gordon University, Queen Margaret University and University of the West of Scotland) but these had not come on line during the course of the pilot.

To fill this gap NES delivered a 2 day Master Class in the pilot areas and this was followed by a variety of day courses offered locally covering the priority areas. The training was widely welcomed. However staff expressed the view that they needed more in-depth training in the more commonly used pathways, in particular Mental Health and Well Being, and regular refresher training in the less well used pathways, such as Homelessness and Youth Justice where local conditions could change quite regularly.

The provision of training to staff from local resources proved very time consuming and stressful for managers but it was recognized that this was not likely to be a permanent need as staff undertook more training provided nationally. However the issue of the provision of CPD for qualified nurses in the future may need to be addressed.

Concern was expressed that taking staff away to pursue training was likely to have a detrimental effect on existing staff capacity and this would need additional consideration. In addition some staff need to upgrade their academic skills before undertaking Masters level modules and this also needs to be factored in to planning for staff training.

Status of Cases at End of the Early Adoption period

By the end of May 2016 P&K had closed/discharged 50 (47%) of its cases and D&G 79 (26%). The difference may have been caused by D&G Nurses sometimes keeping cases open but on reduced intervention. Many of the children had been referred on elsewhere, particularly in the case of P&K. This may indicate a need for further training in order to build confidence in the skills in the School Nurse workforce.

Table 12: Percent children with certain Outcomes of Intervention for Closed Cases

	P&K % Outcomes	D&G % Outcomes
Child Development Team	31
Elsewhere in NHS	2	4
Patient Declined (or DNAs)	13	1
CAMHS	24	8
GP	7
YPHT	4
Central due to Immunisation	7
Incontinence	2	1
Intervention Completed	11	68
Left school		8
Foster Care		3
Educational Psychology		1
Physiotherapy		1
Social Work		1
Other		3

By the end of the early adoption period around two thirds of cases were open in D&G and a third in P&K (there was a relatively high proportion where the outcome was unknown). However this does not take into account the complexity of cases in the respective areas, nor whether the term 'open' meant the same in both areas (in discussion it became apparent that some School Nurse were keeping cases open so that they could keep a watching brief over certain children but this did not necessarily entail a high level of intervention).