In my role as school nurse team lead I have the privilege of working with colleagues who are committed to improving the health outcomes for children and young people and yet it must be acknowledged how challenging this role is. Having worked in School Nursing for 15 years, I have witnessed the increase in demand for school nurses in almost every aspect of their work. Through my work with SAPHNA I have seen how this increase is reflected across the UK and how one of the current most concerning areas for the workforce, is the demand within the child protection arena.
At SAPHNA, discussions about the role within the child protection arena for school nurses are dominating professional forums and webinars at the moment and with good reason. The publication of the revised Working Together document in December 2023 has prompted genuine concern among public health professionals – should a school nurse be lead professional for a Section 17 process? What is the impact on the delivery of the Healthy Child Programme? With limited capacity and reduced workforce what is the impact on the wellbeing of the workforce?
NHS Safeguarding has recognised the importance of local practitioner intelligence and through forums such as SAPHNA's Safeguarding the Safeguarder webinar the concerns are shared in a safe space, good practice highlighted, and clarity of the national picture disseminated. So, what are we hearing?
School nurses have long been concerned about the amount of inappropriate time they spend in supporting children and families in child protection, child in need arena and the wider safeguarding work including strategy meetings and professionals' meetings. Practitioners report that their attendance at these meetings can often feel like a tickbox exercise. School nurses are often viewed as ‘health’ by social care colleagues and therefore fulfil the need to have ‘health’ around the table. Practitioners have expressed their frustration with this approach as it is often not in the best interests of the child and family involved and is an inappropriate use of their time. Working Together (HM Government, 2023) states the process should be about having the right people around the right table at the right time. Yet in reality this is not what we are hearing from frontline practitioners, in fact the Working Together 2023 revision has escalated this concern, school nurses already report being asked to be the lead professional in S17 processes and the reasons for the request are unfortunately not that a public health issue is the main concern but that children's social care colleagues do not have capacity, that the school nurse is known to the family and now, that Working Together 2023 states that school nurses can be the lead professional.
These concerns were expressed clearly at a webinar jointly facilitated by SAPHNA and Institute of Health Visitors in March 2024, practitioners were given the opportunity to hear from the Department of Health and Social Care (DHSC) about the changes to Working Together 2023 that specifically impact health professionals and then from NHS Safeguarding with the opportunity to explore responses and concerns. Local practitioner intelligence demonstrated the level of concern with reports of staff saying they will resign if asked to be the lead professional for the S17 process, staff are already feeling overwhelmed and unable to deliver the core elements of the Healthy Child Programme where a school nurses' role is in promotion, prevention and protection.
So how do we support our profession through this challenge?
We often struggle to explain our role, measure the impact and value, so how can we expect others to fully understand the importance of what we do compared to a safeguarding procedure? This lack of understanding of our role by partner agencies, commissioners and policy-makers leads to the mistaken assumption that we have capacity to take on processes like a S17 assessment when other services do not.
School nurses need to be clear and vocal about where we can offer ’best value’. There are various documents and guidance that can support the workforce to clarify the role. ‘What is the role of the School Nurse’ April 2022, is a publication from the Local Government Association that highlights and defines the role of a school nurse, who they are commissioned by and how they contribute to the vital health and wellbeing of 5–19-year-olds. The document explores the full range of interventions which school nurses can offer and their impact on key government priorities such as reducing child health inequalities, emotional wellbeing and mental health, encouraging healthy weight and childhood immunisations. School nurses are specialist community public health nurses who work with children, young people and families to improve health outcomes, reduce inequalities and vulnerabilities. The increasing number of reports being published about the poor state of children's health in the UK, widening health inequalities, reducing childhood immunisation rates, all provide the evidence that the role of the school nurse is one that should be valued and promoted.
We need to be able to articulate the essential role that School Nurses play in the promotion of good child health, prevention of ill health and the protection from harm. There is no question that safeguarding is not part of the role of the school nurse, it is an integral thread of all that we do, but the best way school nurses can protect children and young people from harm is to ensure effective delivery and accessibility of the Healthy Child Programme. We need to be able to express and share how essential the ‘early Early Help’ work that school nurses do is, and how much it contributes to the identification of vulnerability, reduction of health inequalities and improved lifelong health outcomes for our children and young people.
In order to arm ourselves with knowledge school nurses need to have a good understanding of the Working Together 2023 document, the implications for health professionals and the next actions needed. The document was published in December 2023 after a consultation process, to which SAPHNA and other organisations responded to. The Department for Health and Social Care clarified some of the changes specifically for health, changes that were made following the consultation. The finalised guidance addresses some of the concerns of health professionals, clarifying that health practitioners can lead Section 17 cases if they have the capacity and capability to do so and if this is right for the child and their family. The document clearly says that the ‘lead practitioner should hold the skills, knowledge, competence and capacity to do the work; with the majority of school nursing services running at minimal or negative capacity this is not possible Acknowledging that frontline practitioners are experiencing a very rigid interpretation of the guidance by partner agencies emphasises the need for the school nursing workforce to having a good knowledge of the document, this may then allow school nurses to feel confident in challenging inappropriate requests from partner agencies. Reflecting on my own practice in recent months it has been useful to be able discuss the Working Together guidance with colleagues from partner agencies, finding that often their knowledge is limited but leading to a joint understanding that the needs of the child and family needs to remain the priority.
In terms of next steps for the guidance this is where we need to ensure that the voice of the school nurse is heard. The document calls for local protocols to be created in conjunction with integrated care board's, using the guidance, clearly defining what will work in the local area with the needs of the community identified and the workforce available. School nurses need to be at the table, to not include a representative from public health would be shortsighted and lead to potentially further confusion for, and frustration from the workforce. The local protocols should be in place by December 2024 and yet again local practitioner intelligence reports that there is little evidence of these discussions involving public health, if indeed they are happening at all.
School nurses are specialist public health nurses and yet it can feel a challenge to have any public health role when the demand for the bureaucratic processes of child protection is so high. As school nurses we need to be able to articulate our role, understand the ask as stipulated in Working Together (2023) and use our professional organisations to support and advise. As Prof Kevin Fenton said recently on a new publication from the Faculty of Public Health ‘The simple truth is that #publichealth matters. It keeps us safe from infectious and chronic disease threats, build resilience in our society, contributes to economic prosperity and ensures a fairer future so that everyone can live better for longer’. School nurses are a vital part of this offer.