HC Deb 16 June 2004 vol 422 cc260-7WH 3.30 pm
Mrs. Gillian Shephard (South-West Norfolk) (Con)

I am delighted to have the chance to raise some important issues about an unsung, yet vital part of the health service—the school nursing service. When Minister for Health, the hon. Member for Pontefract and Castleford (Yvette Cooper) said: 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".—[Official Report, 20 April 2000; Vol. 348, c. 1128.] It was that role of

providing a safety net for children who have perhaps slipped past the routine development checks"— or rather the lack of such a role in the case of six-year old Lauren Wright a constituent who died from abuse in May 2000—that alerted me to the present day work of school health advisers, as they are now called, and that led me to raise issues concerning the school nursing service today.

I do not intend to revisit the case of Lauren Wright, not least because I have been able to pursue it on many occasions in the House. However, it is worth pointing out that the independent NHS review of Lauren's case produced by the then Norfolk health authority concluded: The health agencies did not give Lauren Wright the best service. If they had, despite all the faults identified by social services, it is most likely that she would have been protected. That general criticism of the role of the health service was repeated in the review's detailed criticism of the working arrangements for the school nurse in the case. There were substantial criticisms of the other agencies involved, namely education and social services, following the case. I had the opportunity to present evidence about it to the Victoria Climbié inquiry. As became all too common in such cases, there was a lack of liaison and communication between the professionals involved, but I am glad to say that a great deal has been done locally to tighten up procedures.

Some time after the Lauren Wright NHS review was published, I was contacted by Mrs. Jenny Atterwell, a school health adviser now working in the Southern Norfolk primary care trust. She wrote to me very fully in the spring of 2003 and I will read some extracts from her letter. Among other things, she said: I became aware that your understanding of the current school nursing service was slightly out of date. That was the case, but she put me right, as have subsequent things that I have done. She explained the work done by the school nursing service and said that the advisers and members of the team in her area consist of school health advisers, a staff nurse and a school health assistant. The school health adviser's role mainly consists of child protection work … working with school aged children/young people and their parents who are experiencing health or social problems and managing the day-to-day running of the team. Staff nurses mainly provide health care plans for conditions such as diabetes, epilepsy, allergies etc … reviewing of child health records moving in and out of the area and providing advice and support to parents on issues such as bed wetting and behavioural problems. The School Health Assistants, who are nursery nurse trained, provide a screening service of vision, hearing and height to 5 year olds in school. The Staff Nurse and assistant work independently but and under the guidance of the School Health Advisor. Mrs. Atterwell gave further details of the child protection role of school health advisers. She went into detail about what was required when there were case conferences from the health service, what was required in reports and in working with child health records. I think it significant that she added: The child protection role of the School Health Advisor has increased dramatically over the last 2–3 years … I have no reservations whatsoever in saying that child protection has to be of the utmost priority … However I would also say that I did not enter the school nursing profession to deal almost exclusively with child protection and at times I almost feel like a glorified social worker. The public health role of the school nursing service has almost disappeared. This role includes a lot of preventative and supportive work with children and young people, e.g. health promotion and drop-in services in high schools. I feel strongly that if there is a lack of preventative work by a number of agencies, then we will see, and I believe already are seeing, a significant rise in children and families experiencing increasing difficulties with health and social problems. She concluded with concerns about what she described as the need to address the current serious under resourcing of school nursing services in central Norfolk. I shall raise with the Minister later the implications of that last remark. What is clear from Mrs. Atterwell's letter is that we cannot do without the essential role played by the school health advisory service, not only in child protection work but in preventive public health work with children, young people and their parents and other agencies. There will be increased demands on the service as a result of the Green Paper on children, and no doubt the forthcoming public health White Paper, which I believe will be published this summer.

The demands on a service that I already perceived as being overstretched were clarified further in two excellent meetings that I had recently with the school health advisory teams in the Southern Norfolk and West Norfolk primary care trusts. Both meetings revealed teams of enthusiastic and committed professionals. They were brimming with ideas about what their service should do, how it could be improved, how it might be expanded and so on. At present, the Southern Norfolk team is in the throes of reorganisation and there are problems about access to files and other information, but it has not diminished the team's appetite for the job and it is time-limited—the reorganisation will one day be completed.

Both teams defined their areas of responsibility in a similar way and had similar views on the way in which the skills of differently qualified members of the teams should be used. I should be interested to hear the Minister's view of the career path in the school health advisory service, what kind of qualifications people should have at different stages in their career and how easy it is to progress from one set of qualifications, and therefore the duties and responsibilities, to another.

In the two teams, the lead school health adviser takes responsibility for organising the service, for service development and for professional development. The lead adviser also has an important child protection role to ensure that there is an extremely prompt response to child protection cases, for which everything must be dropped, and to other crises.

Newly qualified school health advisers are the major case load holders, setting up and running clinics and drop-in centres, care planning for children's complex health needs in schools—the cases are increasing all the time—dealing with child protection involving health assessments, conference attendance and working with a core group of the other professional agencies in health, education, social services and so on. They also undertake health education, facilitating the training of school staff, curriculum development and responsibility for looked-after children. Team members at staff-nurse grade share that work and review the movement of health records in and out. The importance of that responsibility cannot be over-emphasised, given the mobility of the population and the fact that so many child abuse cases eventually reveal a defective sharing of information.

School nursing support workers, who perhaps have an NNEB qualification, organise and run screening for five-year-olds. They refer children as appropriate to GPs, audiology, ophthalmic services and so on.

The Minister will be familiar with the main message from my meetings with the teams: overstretch. In the West Norfolk PCT team, in order for staff numbers and grades to come into line with the national case load size, as outlined by Dobell and Jackson, there needs to be an additional 157 hours a week, or to put it another way, the team is running with 42 per cent. of its appropriate staff quota. The staff nurse role has 38 per cent. of its required capacity, and the nursery nurse role only 22 per cent. On the other hand, a specialist school adviser, who works in the two special education schools in the area, provides 115 per cent. of the required capacity. That is an organisational difficulty, but it does not help much in the other areas of the work.

The Southern Norfolk PCT team describes itself as "seriously depleted", adding that its lack of numbers is not reflected in our enthusiasm, dedication to our client group, and our professional standards which remain high. However, all team members agree that the level of activity in some areas of practice has increased significantly leading to a reduction in overall service, increased invisibility of the service to schools and raised levels of stress amongst team members that borders on being unhealthy. The School Nursing Team agree that this situation cannot continue. The Minister should be concerned about that evidence. It is not that the Government have not put more resources into the NHS, but the members of the teams, and my perception, point to a lack of policy priority for this area of work relative to other parts of the health service. That was probably always so. There are more glamorous and high-profile areas, and areas to do with the Government meeting targets, reducing deaths from cancer and heart disease. All of us understand that, but the requirements of the Children Bill and the public health White Paper can only put more emphasis on the role of school health advisers.

Now is not too soon for the Minister to be clear about her strategy for the future of school health advisers. She is bound to say that a review is going on under the chief nursing officer, but I am sure that she has her own views about what that review should say. I cannot believe that, if she has had any exposure to these professionals in the health service, she will not agree that those groups of people could do much by way of early intervention to prevent escalations of health problems and behavioural difficulties in children as they become young people.

From my experience in public service over a long period, I know that the school nursing service plays an invaluable part in helping and supporting young carers, for example. That is particularly apposite, because it is national carers week. It provides a discrete, confidential service for young people with health or emotional difficulties in school. In our county, it backs work in schools through projects such as the healthy Norfolk schools initiative and it provides the necessary professional expertise in child protection. It would like to be able to provide a full screening service for all five year-olds. Not so long ago, it was possible for it to do that in our area, but now it does not have the resources.

The Minister might like to give us her views on how valuable she thinks such a screening service would be. There may be professional differences of opinion. Some may say, "What's the good? It is a snapshot. Once you have done it, all kinds of other things can emerge, and you are not going to go back and revisit it." I understand that, but I am breaking my promise to the Minister somewhat in saying that, in the case of Lauren Wright, such a screening might have been enough to avoid her death. We cannot say whether there were many other factors. There is no doubt that, had there been a routine screening of five-year-olds in that school, the bruising that that child was suffering over 18 months—she died when she was six—would have had to be discovered by a professional view.

If school health advisers had the resources, they could give early help and advice to the parents of children with disabilities. Perhaps the Minister will comment on that. I would be glad if she did. Only last week, I visited a marvellous special school, the Chapel Road school in Attleborough, Norfolk, where parents were saying that it provided an immense amount of support, once the children were at school, on how to cope with one member of the family who happens to have disabilities. However, if professional health advisers were involved as well, that would be an extremely useful step. There could be so much more support for those parents.

In "Every Child Matters: The Next Steps", published earlier this year by the Minister for Children, much was made of the need for early intervention, or, to put it another way, for preventive work on the part of all relevant agencies. That document states on page 7 that consultation established that there was a need to intervene earlier through better information sharing, a common assessment framework, lead professionals, multidisciplinary teams, and the co-location of services through extended schools, Sure Start Children's Centres and other community sites. The Minister will feel that that could be a text for the work of the school health advisory service but, obviously, it needs to be equipped for the job. In a letter that it prepared for my meeting with them, the Southern Norfolk primary care team spoke about the public health role: The School Nursing Team agreed that this was an area of practice that had become sadly neglected. We agreed that many of our current areas of practice had a public health link. Many issues regarding Child Protection are related to public health e.g. poor housing and poverty leading to poor health. However all we, as a primary care group, are doing is crisis managing such public health issues and not providing any early intervention or preventive input. It put forward, as a team of professionals, proposals to improve that situation: helping curriculum development in schools, health focus days, improving access to the school nursing service, up-to-date materials, knowledge, classroom support and so on. The Minister will undoubtedly be familiar with all those things. She is bound to be an enthusiast for this area of her responsibility—she could not have had contact with the service without being an enthusiast for what it does, which is very infectious and very impressive. She is bound to see the curious discrepancy between the aspirations of "Every Child Matters" and what is happening on the ground.

The school health advisory service could do so much to fulfil the promise of intervening earlier through better information sharing and so on, as outlined in "Every Child Matters". It now needs a clear Government strategy for its work. Those in the service need to know more about ministerial thinking on the qualifications framework and on the career paths of those who work in it. I hope that Ministers understand that they have, in that part of their service, a group of dedicated, enthusiastic and committed professionals, whose provision and expertise are entirely in line with the demands of today's children and parents. I know that I shall not be disappointed by what the Minister is going to say.

The resources arc in the health service. It is a question of making this part of the service as much of a priority as possible. The school health advisory service needs the resources and that policy priority. I hope that we will hear from the Minister today that she intends to equip it to fulfil its role to the utmost.

3.49 pm
The Minister of State, Department of Health (Ms Rosie Winterton)

I congratulate the right hon. Member for South-West Norfolk (Mrs. Shephard) on securing this important debate. I assure her at the outset that the Government recognise and agree with her about the important contribution that school nurses can make to health priorities such as obesity, sexual health, teenage pregnancy, health inequalities and child protection, and in giving support to carers.

The other day, I was talking to my father, who happens now to live in Norfolk, but who used to be a head teacher in Doncaster, in an ex-mining area. He talked to me about the important role that his school nurse played at that time in tackling some of these issues. That conversation and meetings that I have held with school nurses have given me an understanding of the points that the right hon. Lady makes.

The contribution of school nurses was also highlighted in "Making a Difference", our strategy for nursing, which was published in 1999. Following that, the Government funded a three-year national development programme for school nurses, including the publication of a school nurse practice development resource pack, the establishment of leadership posts and the consideration of funding for specific projects that would support school nurses.

Mrs. Shephard

I wonder whether the Minister understands that although specific projects can be useful in addressing a particular need, they can also be a plague for professionals—whatever profession they are in— because they can distort their local priorities. Such professionals may also sometimes feel threatened by specific initiatives. I am sure that she knows what I mean—I am not sure how much such initiatives help.

Ms Winterton

Particular projects can be of great assistance in, for example, spreading best practice and re-emphasising the particular contribution that can be made. It may sometimes be difficult, but it is right that we should devolve power. Shifting the balance of power is about allowing local primary care trusts to make decisions that suit their local priorities. However, it is often helpful to show how specific projects can contribute towards making a difference in some of the areas that I have outlined.

Mrs. Shephard

May I give the Minister an example?

Ms Winterton

Of course.

Mrs. Shephard

In the West Norfolk primary care team, the school health advisory service has been asked to provide a particular service for the "healthy Norfolk schools" initiative, which has its roots in a national initiative. The criteria that must be applied in identifying the schools to take part in that initiative are based on the numbers of free school meals taken by the pupils. However, the measures of deprivation applied by the team are slightly different, and do not necessarily coincide. I am sure that the Minister can see that although there is much value in such initiatives, they may, on occasion, cut across local judgments.

Ms Winterton

I would be interested to know whether there are particular difficulties in the project that the right hon. Lady mentions. However, I believe it to be important that we use local projects and local initiatives—particularly in the school nursing service—to show some of the benefits that can be brought.

The right hon. Lady mentioned the 2003 Green Paper "Every Child Matters", which highlighted the importance of preventive services for the school-age population, and the need for integrated children's services, including school nurses and health visitors. She drew particular attention to the case, in her own constituency, of Lauren Wright, in which that lack of integration led to tragic results.

The right hon. Lady also said that we were undertaking a review through the chief nursing officer. The review is examining the contribution of all nurses, midwives and health visitors to children's services. However, it has specifically considered how school nurses can be supported in promoting and protecting the health and well-being of vulnerable children as part of their child-focused public health role. The recommendations of that review will be published shortly, but all those different strands point to the need to build the school nursing work force. I also acknowledge that the work force's present small number in relation to the range of important health issues that they have to tackle means that we must take steps to ensure that it is possible to enlarge it. We have undertaken a range of initiatives to support local organisations in the recruitment, retention and return to practice of school nurses and others in nursing disciplines. Most importantly, we have increased the number of nurses by about 67,000. Therefore, there is a larger pool to draw on. In the right hon. Lady's strategic health authority, about 3,000 more nurses and midwives are working in the national health service than there were in 1997.

As we have said, it is up to primary care trusts, which are the cornerstone of the NHS and are best placed to ensure that the local health service reflects the needs of the local community, to examine the changes that need to be undertaken. Between them, the Southern Norfolk and West Norfolk PCTs have been examining how to spend some of the increase of £27 million that they have received this year on improving school health services. A number of actions have been taken and I am sure that the right hon. Lady is well aware of those. I do not have time to address them in enormous detail just now, but I am sure that she will know that only last Friday, a conference was held in Norwich. It examined the services that are currently available, the skill mix in the nursing teams, and future requirements. That means that Norfolk county council and the PCTs are working closely together to ensure that they have a properly integrated service. At a local level, the message is getting through that the issue that we are discussing can play an important part in public health matters.

The right hon. Lady referred to "Choosing Health?", which will be published later this year. I have every expectation that it will receive many responses about school nurses and about what can be done with the school age population, particularly on preventive health, but also on some of the screening to which she referred.

In the time that is left to me, I want to address some of the particular points that were raised, for example, on career paths and training. We are examining the development of core competencies for those working with children, as was set out in the Green Paper, to see how their career development can be improved. As I said, the chief nursing officer review has also considered the training needs of nurses who are working with children—particularly those who are vulnerable.

On examining child protection issues, we are encouraging more proactive work with children who are most vulnerable and examining promoting early intervention, in the way that the right hon. Lady outlined, and offering support to families. Again, that is in keeping with the Green Paper's recommendations. She referred to screening—routine weight measurements on school entry. Evidence from several reports is being considered that such screening can lead to improved protection. That consideration is taking place within the overall national framework for children; again, publication will be later this year. There is a range of ways to do things at national and at local level.

We are examining the important points that the right hon. Lady made about the role of schools nurses. I endorse that completely and the Government have been committed over a number of years to examining the role of such nurses and to how we can develop it further. The whole agenda, involving the public health consultation and the examination of the role of nurses and carers and the support that they can be given, means that the role of school nurses will be increased as she has suggested.