A campaign for a school nurse in every school has been launched in a bid to reverse a ‘steep decline’ that has seen a 33% fall in the number of school nurses since 2009. A new report – based on a recent roundtable discussion – sets out the significant barriers that exist and offers some potential solutions.
The figures are stark: The number of qualified school nurses has fallen by 33% in the last 13 years from 1 135 to 852 – many of whom it is feared will no longer be practising in schools.
Likewise, the number of NHS professionals working in school nursing (including the qualified school nurses listed above) has fallen by almost 1 000 – from 2 915 to 1 945.
A new report has laid bare the impact of this 'significant loss of expertise, knowledge and skill' that we have seen between September 2009 and December 2022.
The figures (NHS, 2023) show that the number of qualified school nurses first fell below 1 000 in 2019 and has been in decline ever since.
And the figures also hide 'great variation' across England with children and young people facing a postcode lottery of provision 'with very serious consequences for families and for child health'. It warns that in some local authority areas, school nursing is no longer commissioned at all. Furthermore, the report emphasises that many of the 852 school nurses listed in the data 'will no longer be practising as such'.
The report is based on a roundtable discussion held in December between nursing leaders, charities and NHS and government representatives and hosted by the Queen’s Nursing Institute (QNI), the College of Medicine, and the School and Public Health Nurses Association (SAPHNA).
The report's message is clear: 'Current services are insufficient to meet need. School nursing roles and services have been eroded in recent years and in many instances, resources are now insufficient to deliver the government’s National Healthy Child Programme.'
Identifying the problems
The report cites 'a reduced focus' on funding for services for children and young people, warning that 'school nursing has become depleted resulting in school nurses feeling overwhelmed and unable to deliver all elements of their role'.
It adds: 'This then leads to a cycle of recruitment and retention challenges.'
The report explains: 'School nurses are skilled and qualified professionals, educated to post-graduate level, whose practice is informed by a biopsychosocial perspective and grounded in prevention.
'The roundtable heard it was a role which traditionally involved considering the broad range of biological, psychological and social factors, and intervening appropriately to support not only children and young people but their wider families. Increasingly, however, roles do not offer opportunities to use these skills.'
One participant described the job now as 'firefighting and plugging gaps'. Another spoke of school nurses often working 'solely as safeguarding nurses – not public health professionals'.
While acknowledging the 'crucial' role school nurses play in safeguarding, the report warns that a 'disproportionate amount of school nurse time is often focused at the child protection and child in need end of the continuum'.
It continues: 'The risk is that their involvement is bureaucratic rather than beneficial to improving outcomes for the child. The change in the focus of the role means that it is difficult to retain experienced staff, who may be disillusioned by an inability to use the full range of their skills. It also makes the role less attractive to prospective nurses. This is a key factor in understanding the crisis not only in children’s health but also in the school nursing workforce itself.'
Another consequence of the lack of school nurses is that 'an increasing number' of schools are now employing their own nurse. The report warns: 'This is usually in response to the reduced visibility of school nurses from the local authority. However, these school-employed nurses tend not to be qualified school nurses and are often professionally isolated, which can be problematic.'
In particular, the report pinpoints the Health and Social Care Act 2012, which transferred responsibility for many public health services, including school nursing, from the NHS to local government at a time when funding for local authorities was being cut back severely due to austerity.
A lack of national oversight is also a problem, participants at the roundtable heard: 'There is no central government oversight, so it is not possible to state with certainty how many school nurses are in place and in which areas, or to comprehensively know where services have been increased or decreased,' the report adds.
Identifying the solutions
The roundtable recognised the importance of building political will, clarifying the role and responsibilities of school nurses, and improving school nurse workforce data to better understand how their work has an impact on outcome measures.
Ultimately, the roundtable said that a 'coalition of support for school nursing' had to be built – not least encouraging Integrated Care Boards to prioritise school nursing within healthcare strategies for children and young people in their areas. And there is hope, because – as was reported at the roundtable – from November 2023 the chief nursing officer has taken over professional leadership of public health nursing meaning that school nursing will be part of their forthcoming strategy. Furthermore, NHS long-term workforce plan has set out an ambition to increase school nurses by 48% – although as the participants pointed out this relates to training places, not funded roles.
Changes to how school nurse roles are commissioned could also prove fruitful, the discussion heard, with one case study from Tower Hamlets in east London having seen GP surgeries forming a social enterprise that commissions additional service including school nurses.
The report adds: Local authority representatives at the roundtable spoke of a desire to be braver in commissioning decisions. There was some optimism that the new NHS provider selection regime could ultimately help support this. These new procurement rules have an express aim of supporting collaboration across systems, increasing flexibility in processes, and ensuring all decisions are made in the best interests of service users.'
Participants also want to see more elements of the government’s flagship 5 to 19 Healthy Child Programme mandated for delivery by school nurses.
The report adds: 'The need to see school nursing as one key resource within a system, and to have it be part of an integrated approach, was highlighted. Considering how school nurses can fit in as part of the broader system, and how to capitalise on and complement the resources already present through initiatives like social prescribing, could be a valuable way of reinforcing the roles.
'Where pots of money are available for new projects, such as mental health support teams, there would be real value in considering how school nurses could provide such services. Rather than reinventing the wheel each time, those resources could be invested in school nursing.'
A School Nurse in Every School
SAPHNA, the QNI and the College of Medicine have now pledged to work together to begin a campaign for a school nurse in every school. In 2021, the College of Medicine included the goal in its Hope for the Future manifesto and Dr Michael Dixon – who chaired the roundtable – said the discussion and report were 'an important step' in achieving this.
He added: 'Participants pledged to move into action to help ensure school nursing is prioritised with investment in this highly skilled workforce.'
Speaking to CHHE after the roundtable, Sharon White, CEO of SAPHNA, pointed to a 'horrifying downward trajectory' in children’s health, including re-emergence of diseases such as rickets, scurvy and malnutrition and rises in vaping and sexually transmitted diseases amid other challenges.
She said: 'We know that this workforce is a crucial part of the solution and it is no coincidence that after over a decade of disinvestment aligned to the Treasury’s Public Health Grant cuts, and an around 35% loss in staffing, we find ourselves in this dire situation.
'As leaders of the Healthy Child Programme who are public health nurse specialists, expert at promotion, prevention and protection, there is no one better placed to help our children and young people repair, recover and restore.'
Sallyann Sutton, SAPHNA’s interim professional officer, said that the Healthy Child Programme 'cannot effectively be delivered' because school nurses have declined to such an extent.
She added: 'The result is sketchy delivery, a postcode lottery and an exhausted workforce. Our children and young people deserve better. They must have access to this universal reach – personalised in response, promotion, prevention and early intervention programme. It was humbling to have so many strategic partners at the table committing to ensuring every child and young person has access to a qualified school nurse.'
Dr Crystal Oldman, chief executive of the QNI, added: 'School nursing services have been allowed to atrophy since they were transferred to cash-starved local authorities. We urgently need to invest in school nursing services that have a proven positive impact on the physical, mental and emotional health of children and young people at a crucial time in their lives.'