HC Deb 20 April 2000 vol 348 cc1124-32

Motion made, and Question proposed, That this House do now adjourn.—[Mr. McNulty.]

12.31 pm
Mr. Edward Davey (Kingston and Surbiton)

I am grateful to the Chair for granting me this debate, just before we break for the Easter recess. The motivation for requesting it arose from visits to schools in my constituency, where I met teachers, head teachers and parents who are worried about the reduction in Kingston's local school nursing service. Having spoken to representatives of the health authority, I am aware that, last year, the service was cut back. A major review of the service has been carried out, but no decision has been taken. Meanwhile, the service is left in limbo and there are insufficient school nurses to serve the 20,000 children in Kingston's schools. That is a matter of deep concern.

I am aware of the broader issues and, in the desire to prevent the debate from becoming too parochial, I shall give my view of the importance of the role of the modern school nurse and how it fits in with Government policy. The days of Nitty Norah are long past. I remember lining up in the queue to have my hair checked with the head lice comb, but the school nursing service changed many years ago. Now, it is far more involved in real health screening, with highly skilled professionals delivering added value through the health care that they provide to schoolchildren.

School nurses conduct proper interviews to compile a profile of a school; they assess children for specific problems at different ages; and they run immunisation and vaccination programmes. They are in regular contact with schools, so that problems picked up by teachers can be referred to the school nurse. They help to ensure that vulnerable children and those on the child protection register can talk to a private and confidential ear. That counselling, listening and advocacy role is an often overlooked part of the school nurse's role.

Many school nurses run drop-in clinics, not only for schoolchildren, but for parents and teenagers outside school, in which they deal with issues ranging from mental health to sexual health. They run enuresis clinics and parenting programmes. School nurses play an essential part in health education and the promotion of healthy living. That sophisticated role should be recognised, developed and given proper investment.

The Government have recognised that in their documents "Saving Lives: Our Healthier Nation" and "Making a Difference", which specifically refer to the role of the school nurse. It fits well with the health improvement programme, sure start and the healthier schools initiative. That role could play a key part in the way in which primary care groups and trusts deal with public health policy.

"Making a Difference", which was published in July 1999, states: We need to develop the public health role of the school nurse too, building on the opportunities their contact with children and young people provide. I therefore acknowledge and put on record the fact that the Government say the right things. When they develop their forthcoming policy on sexual education and sexual health—the Minister may want to refer to that—I hope that they put school nurses at its centre.

The need for early detection of special educational needs is part of public policy. Do the Government provide sufficient guidelines to health authorities? Are they placing sufficient emphasis on their statements to health authorities? Are they providing the resources to ensure that a key role such as that of the school nurse can be properly fulfilled? I am worried that they have not yet done that.

The Government have a problem. The history of the school nurse service shows that the experience in different communities is diverse. No Government have developed a national framework from the start of the school nursing service. Some people believe that it began in 1892, whereas others trace it back to the 1870s. There were changes in the 1960s and in the early 1970s, and the Court report was published in 1978. The previous Government also made changes.

The importance of the school nurse service has been recognised, but there has been a lack of willingness to provide a proper framework. It has fallen between the stools of health and education and has never received the priority that it deserves. I hope that the Government will develop the statements in their documents to provide a clear lead.

There is a great need for such a clear lead. I have read several academic studies in preparing for the debate. A paper that was published by Berry Mayall and Pamela Storey in 1998 put that need in the clear context of experience in schools. The paper discusses current pressures on schools through, for example, local management of schools and large classes. It makes the point that teachers are almost too busy to provide much of the lay, informal care that they used to provide. Children therefore rely increasingly on school nurses, whose numbers are reduced.

There is a genuine problem, which merits debate. At the end of the paper Berry Mayall and Pamela Storey make the point that other health service purchasers claim that a school health service largely duplicates other health provision—GPs, primary care groups, health centres—in the health service. However, there is a key drawback, which I hope that the Minister will recognise, to that argument.

Children cannot easily seek help on their own. There are many reasons for that. They may not think of doing it, traffic may be a problem, health centres may be a distance from their homes. It is often the custom that parents look after the health and welfare of children. Children expect parents to do that and they do not often take the initiative. If health care is not provided in schools, it might never be provided for many children, especially our most vulnerable children. Researchers and other commentators are right: we need to develop the service.

I was especially anxious about the lack of statistics and information on the subject. The data are no longer held centrally. When I asked the Library for information on the number of school nurses, I received figures from 1990 to 1994. They showed a reduction in the number of school nurses over those years. There were no data after that. The Library claimed that employment data no longer provide such a breakdown. The Minister may want to consider that and obtain the data so that the Government could understand what is going on and ascertain whether the number of nurses is decreasing. That is certainly what has happened in my area.

The Royal College of Nursing told me that it is very worried and that the service was the first to be cut because it is not noticed so easily. It provides preventive health care and is therefore much more vulnerable. I hope that the Government will give the matter the attention that it deserves.

I also refer the Government to a draft national framework for school nursing practice published in October by the Community Practitioners and Health Visitors Association, working with the Queen's Nursing Institute. They advocate what I am talking about: there needs to be a clear framework to provide such a vital service. The introduction to the document states: In the absence of a clear national framework or strategy for the School Nursing Service many service developments have been ad hoc and confined to individual Trusts. With widespread disinvestment in the service over recent years, school nurses have often had to fall back on their individual skills and ingenuity with few resources. A Government who rightly put huge emphasis on public health and a primary care-led NHS, cannot be happy with that. I hope that the Minister will make a particular comment on that draft national framework and on whether the Government are considering adopting it. I hope that they will do so because it would support a vital service.

As primary care groups and primary care trusts develop, I ask the Government to consider giving them guidelines to ensure that the school nursing service and the school health service generally are not forgotten in the allocation of resources locally. It might be too tempting to the GPs who will inevitably lead PCGs and PCTs to forget community nurses and particularly school nurses, whose voices may not be heard as loudly as they ought to be. Given the amount of money that we are talking about—a relatively small sum in the overall health budget and budgets of PCGs—that would be a mistake. The Government rightly talk of joined-up government. The service could provide so much and meet so many of their social objectives, so it is important.

I return to the comments of those in my constituency, who provoked my interest in the subject. As I said, there have been cuts, and, as a result, the health authority wanted to review the service and to consider how to use its pot of money more effectively. That review was led by the school nurses, and rightly so. I congratulate the people involved in it; many positive things came from it. They have talked about using best practice and conducted a wide review of the literature and what is going on elsewhere. They are proposing to move away from a service based on principles of routine screening to more preventive, targeted health care, which is probably right.

The review also uncovered many negative aspects, especially the impact of the cuts. School nurses in Kingston qualified the proposed service structure in which new services would be developed by saying: The proposed structure can be developed within current resources. However, school nurses feel that they will not be able to deliver all of the service principles with such a structure. In other words, as a result of the cuts, they cannot deliver the service that the review required.

Although recent discussions with people who are much involved in the school nursing service have revealed that they have done many innovative things, such as ensuring that the child protection scheme has been properly covered and pushing through the vaccination programme, they cannot give certain vulnerable children the extra support that they need. They cannot provide regular, weekly contact with schools or develop drop-in centres. They certainly cannot assume the health promotion role that the Government clearly want them to play. Even after the review, the service faces great problems.

Although some vacancies are to be filled, we have only four school nurses looking after almost 20,000 children. That shows the size of the problem. Even when the vacancies are filled, and there are perhaps seven or eight nurses, there will still be fewer than just a few years ago. It is therefore not surprising that there are problems.

Several schools have written to me about their problems. Lovelace school in Chessington said: The reduction in the number of Nurses available to the schools in the Borough has been a great concern to the Governors at Lovelace for a while now … It is important, therefore, that Ministers are made fully aware of the implications of such lack of support and are consequently urged to reconsider the funding of the service. St. Philip's school, a special school in Chessington, said: I am writing to express my growing concerns about the School Health Service and the recent impact that the lack of a school nurse is having on the children in this school…I am concerned that we are not going to be able to carry out the statutory annual medicals for all the children this year. That is the extent of the problem that we face. Knollmead primary in Tolworth wrote: Schools have missed the regular weekly nurse visit. Staff, pupils and parents knew when to expect the nurse and each week in her message book we would put any concerns requiring follow up, knowing that this would be prompt. The loss of this part of the service has been felt and I do urge its restoration for the good of the children. Local schools are very concerned.

I stress to the Minister that the review has uncovered real concerns, which shows that we need a framework. For example, there is a wide diversity in spending on the nursing service per pupil per annum in one health authority. In 1999–2000, Kingston and district community NHS trust spent £13.86, Teddington memorial NHS trust spent £19.69 and the South West London community trust spent £31.56—more than twice as much as Kingston. Such a wide variation in the allocation of funds in the same health authority cannot be right; nor can that deliver the programmes that the Government want to deliver.

Finally, I have a particular bugbear. People talk of Kingston as a leafy borough, as the Deputy Prime Minister did early in this Parliament, but may I explain to the Minister that it is not? There are prosperous areas of course, but it is not homogeneously prosperous. Indeed, there are pockets of severe deprivation in my constituency, and children in schools need help. As the review says, in spite of the impression that Kingston and Richmond is a very affluent district, its Jarman score shows that its deprivation level is slightly above the average for England and Wales. The area includes pockets of considerable deprivation.

There are children who need the school nursing service. I urge the Minister to contact Kingston and Richmond health authority to urge it to provide the service with the resources that it needs. For the country as a whole, the Government should make sure that the service can be properly developed and properly resourced.

12.48 pm
The Parliamentary Under-Secretary of State for Health (Yvette Cooper)

I thank the hon. Member for Kingston and Surbiton (Mr. Davey) for raising this important topic and for making significant points to which I shall try to respond as best I can in the time available.

School nurses clearly provide an extremely valuable service to children. They have been looking after children's health for more than 100 years—the first was appointed in 1894—and they are often the first point of contact for teachers, parents and children requiring health advice in school. They often work closely with general practitioners with primary care and sometimes with specialist paediatricians, when the need arises. They also play an important part in providing a safety net for children who have perhaps slipped past the routine development checks or immunisations offered under primary care in the early years, and have a role in other immunisation and health advice campaigns and in offering counselling to teachers and children in school.

I pay tribute to and give thanks for the role that school nurses are playing this year in delivering the meningitis C vaccination. Without the school nurse network, it would be extremely hard to achieve such an unprecedented roll-out of the new vaccine in such a short time and before any other country. School nurses offer health support to children who have medical needs and can play a crucial role in all stages of child protection.

In the White Paper "Saving Lives: Our Healthier Nation", the Government set out a framework for the future role of school nurses as public health practitioners, including many of the issues that the hon. Gentleman raised. The White Paper stated: School nurses are ideally placed to help children, young people and their parents find the support and services they need. The potential to develop school nurses is a growing element within the Healthy Schools programme and their role is being increasingly considered within other Government initiatives. School nurses can provide support on personal relationships, managing stress and risk-taking behaviour. They can complement primary care services, especially for the most disadvantaged.

School nurses' enhanced child-centred public health role means that they will be working in new ways, operating across traditional professional and agency boundaries which will require multi-disciplinary, multi-sectoral working to deliver high-quality and effective services. School nurses will be expected to lead teams, to include nurses and other community and education workers to assess the health needs of children and school communities and perhaps to agree individual and school health plans and the delivery of those through multi-disciplinary partnerships. They will be involved in immunisation and vaccination programmes and will also contribute to personal health and social education and to citizenship training. School nurses will offer support and counselling and promote positive mental health. The new role may involve work on teenage pregnancies or the housing needs of children who have asthma. School nurses will work with other teams across the community to provide the support that children need.

The Government have set up an innovation fund of £1 million to explore new ways of working for health visitors and school nurses, including new roles and partnerships. Since last summer, 31 health visitor and school nurse leadership posts have been set up across the NHS demonstrating the new roles and ways of working. Those appointments have been made in order to develop and demonstrate the new role and to provide examples of best practice that we can roll out across the country. Health visitors and school nurses form a core element of the innovations network and provide a locus for networking across their own health regions. The posts will be demonstrating the new, ways of working and focusing on the particular aspects of the needs of those local communities they serve, be those the special needs of pregnant teenagers, vulnerable families or deprived neighbourhoods, or the particular problems experienced by black and other ethnic minority communities.

The hon. Gentleman raised the question whether we should have some sort of national framework or standards. He raises an important issue to do with developing the public health role of school nurses and health visitors in practice, and how we implement many of the proposals described in "Saving Lives: Our Healthier Nation". One of the key methods will be through primary care groups and, increasingly, primary care trusts. New partnerships and relationships will evolve, as the primary care groups develop their public health role. That is one of the issues that the modernisation action teams are examining, as part of their work towards the national plan for the NHS to be drawn up this summer. The hon. Gentleman is right to highlight that issue, and we are considering it at the moment.

The hon. Gentleman is also right to point out that there are frameworks in place within which those issues can be developed, such as the health improvement programmes. He did not mention the healthy schools initiative, but that will be an important part of the future role for school nurses. Although parents have the prime responsibility for keeping their children healthy, school is clearly a vital influence on children's health. The healthy schools standard that we have developed provides a structure for the shared responsibility for promoting health and integrating initiatives aimed at the school population. The healthy schools initiative will provide school nurses with the opportunity to contribute to a common health and education agenda and to make those links between health and education that the hon. Gentleman mentioned. A number of other related policy developments recognise the potential for school nurses to contribute to the Government's agenda, such as child and adolescent mental health, parenting, quality protects, teenage parenthood and smoking. The hon. Gentleman is right to say that work on the implementation of the teenage pregnancy report must include the role of schools nurses.

By launching the national healthy school standard in October 1999, the Government set out to give all schools the opportunity to become healthy schools. We also ensured joint working between health and education authorities by funding programmes designed to support the implementation of the national healthy school standard in every local education authority. One of the conditions of funding was that the work programmes should be approved by the relevant chief education officer and director of public health. These partnerships are expected to attain national standards and criteria, and to reach a stage where they can be accredited under the national standard. In turn, they can accredit schools in their area.

We have, in the last week, accredited three health education partnerships—Liverpool, Manchester and Norfolk—with reaching the standards required by the national programme, and we expect all local programmes to be accredited by March 2002. I understand that the Kingston and Richmond healthy schools programme is aiming for accreditation in April next year.

Schools and partnerships gaining accreditation will continue to be monitored by regional and national assessors to ensure that the process is not a one-off, but a continuing improvement in the level of health information and opportunity within school communities. School nurses have a vital role to play within the development of healthy schools.

Healthy schools are an essential training ground in preparing our young people for citizenship and providing building blocks in building a healthier nation. A considerable amount of work has been done in schools in the past. This work has contributed to the development of the healthy schools programme. However, what has been slower to develop in school health promotion programmes, relative to programmes in other settings, is the wider perspective, which recognises the importance of supportive social and physical environments for health promotion.

In Leicester, for example, school nurses are involved in multidisciplinary teams across the community to ensure that there are improvements in housing for children with asthma or children in vulnerable areas. Such work to link what is done in schools, as part of the healthy schools programme, with what is done in the wider community is where school nurses have an important role to play. They need not necessarily do everything themselves, but they can work as part of a team—or as team leaders—to deliver the wider public health roles that the hon. Gentleman and I agree are important.

We believe that the national healthy school standard will encourage the development of that perspective and, through the need to link to local priorities, a greater concentration on local issues can be given, particularly in more deprived areas.

Ten schools in Kingston and Richmond have already received their healthy school award, with a further six schools due to receive their award this May. A wide range of projects is undertaken by the local schools, including an important early introduction to healthy eating through from healthy lunch box work at Buckland infants and nursery school, a refugee compact club at Southborough boys school and an impressive sun safety project at Latchmere junior school.

The hon. Gentleman referred to a fall in the number of school nurses in the area, but my information is that there has not been a reduction. Perhaps he and I could pursue that matter later. The review has addressed important issues and has been an opportunity to examine clearly the future public health role that school nurses can play. It has recognised the value of the service provided by the school nurses.

I understand that the health authority is keen to examine the report from the child health sub-committee of the national screening committee, as one of the elements to inform development of the work locally. The hon. Gentleman talked about national guidance, and the work being done by the child health sub-committee may prove extremely important. It is looking at the evidence base involved in—

It being One o'clock, MR. DEPUTY SPEAKER adjourned the House, without Question put, till Tuesday 2nd May, pursuant to Orders [1st and 23rd March].