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Booster for an unhealthy service

Largely ignored through mountainous NHS reforms, the school nurse is now under scrutiny. Catherine Ormell reports.

Until last autumn, the arrival of a health visitor in school was enough to dampen the collective spirits of Brierley Primary on the outskirts of Grimethorpe. The children sensed needles were about to be plunged into their tender parts, while the staff braced themselves for another protracted child protection crisis. Either way, both knew that something unpleasant was in the offing.

So overworked were these Barnsley health visitors, who combined the job of school nurse with their other duties, they only swooped when necessary. Perhaps an immunisation programme was required, or a height and weight check. In and out with their bulging bags, they were nearly always harassed and in a hurry.

Schools like Brierley, expected the nurses when they saw them - demanding extra help seemed out of the question. But just a few months on, the school nurse has reinvented herself as friend rather than foe. Brierley, which sits on the outskirts of the decaying ex-coal mining community of Grimethorpe, now has a "named" nurse who cuts a familiar figure in the school.

Headteacher Mike Reed says the service has become more user-friendly. "Under the old regime, the school nurse only arrived when something was wrong, and to do things to us," he says, "Now we've got a drop-in service so the children can speak to the school nurse without a teacher being present. They've got a better relationship with her and we're picking up problems earlier, like the child who couldn't see the blackboard, or the child who was unhappy because his father wasn't paying him any attention."

The school gets support on health education policy, and has someone to help with teaching resources and direct them to other agencies when necessary.

The health authority in Barnsley launched a new school nursing service last November, taking on 10 school nurses and six assistants to service the 121 schools in the borough at a cost of Pounds 250,000 a year. And the nurses are already making an impact. Not only are local heads like Reed impressed, but the local sexual health clinic reports a 40 per cent rise in teenagers seeking advice prompted by the nurses.

Barnsley is a striking example of the shake-up that's currently underway in the school health service. A forthcoming report by the Queen's Nursing Institute has found most health trusts in England which supply the service are undertaking a radical review. Co-author and QNI director Pippa Bagnall says: "For the first time in a very long time the purchasers (health commissions) who are buying the service from the trusts want to know what they're getting and whether it's value for money."

Because it's evolved rather than developed, and because it's been largely overlooked by the NHS reforms, the service varies wildly in its make-up and methods round the country. According to the QNI report, the ratio of pupils to nurses swings between different areas from just over 1,100 children to one nurse, to 13,000 per nurse. Some areas have no school doctors, some do. There are pockets of excellence and pockets of old-fashioned inadequate service.

"There's no logic to the provision," says Bagnall, "it's a patchworkIeveryone does something different. The Government's never laid down any guidelines on what should be the baseline service that all children should expect. In fact, there's very little in statute law that actually forces anybody to provide any sort of a school health service at all."

The school medical service was originally introduced in 1908 after the Government became alarmed by the poor quality of recruits for the Boer War. For more than half a century, school nurses fitted the Nitty Nora stereotype - the handmaiden of the school doctor intent on checking verminous scalps and watching out for signs of TB.

But their job description has changed radically. Health promotion, education and counselling have become more important than routine health screening - the latter described by one nurse as "the practice of checking healthy children to check that they are healthy".

In his influential report published last year, Dr Leon Polnay, reader in child health at Nottingham University and chairman of a joint working party of GPs, paediatricians and nurses, recommended scrapping routine medicals by school doctors and replacing them with health interviews carried out by school nurses. She or he could then refer the child on to a paediatrician or other specialist.

Polnay's model results in a better use of resources and elevates the nurse to the powerful position of key health care professional in schools. Jane Naish, the Royal College of Nursing's community health adviser, welcomes it, believing that after several years in which school nurses have felt threatened and demoralised, they are finally making a comeback.

"The school nurse wasn't valued - health commissions and trusts were looking to cut or remove the school health service. But it's back on the agenda now.

"The Polnay report gives nurses a boost. The introduction of mandatory training in 1997 should raise their status and pay grading. What's more, the health commissions have realised they need the school health service and they're buying it," she says.

While there's been no more money available in most trusts, some nurses have benefited from creative re-organisation. In Leeds, for instance, school doctors are not replaced when they resign - the saving has been spent on improving the grading and pay of nurses. In other areas, the introduction of skill mix (organising teams of junior, cheaper staff led by one experienced nurse), has led to an overall increase in the number employed.

But not everyone has shared this positive experience. Peter Rees, headteacher of Park Walk Primary in Chelsea, central London, has a lot of needy children in his school and little support from the school health service. More than 70 per cent are on free school dinners; more than 50 per cent of pupils don't have English as a first language and many are refugees.

In the past Rees says he's had some outstanding school nurses. "Three years ago we had a nurse who did work on posture and hygiene with the children, and stress with the teachers. She knew most of the parents; the children understood what she was doing and why she was here."

But his last permanent school nurse, who'd been in post for less than six months, left in March 1995 and for the past year her work has been covered by locums. "It's a sad and sorry situation," he says. "Routine health checks have got later and later, we're just getting the most bare, basic service, nothing in terms of health education or health promotion.

"Parents are told explicitly and implicitly. 'Go to your GP, that's the real person you need'. Meantime the school nurse is devalued and downgraded.

"But the GPs round here are overloaded and not all parents are conscientious. For some of these vulnerable children, the school nurse is the only health professional they might come into contact with between the ages of five and 11."

Riverside Community Healthcare Trust, who supply Park Walk's nurses, admits it's had special problems recruiting and retaining nurses, particularly because Chelsea's an expensive place to live. The trust is now undertaking the second review of school nursing in four years.

If the health service and the role of the school nurse are changing - the needs of children and schools are changing too. More children with cancer or serious illness now attend school; more neonatal survivors with complex nursing needs are coming into schools. Government policies designed to integrate special needs children are also having an effect.

One of the time-honoured complaints has been that the health authority-employed nurse who pops into the school once a week for some health promotion or screening, is never around to help with hands-on nursing, giving medication or first aid. And because she's an outreach worker employed by the health authority, schools don't have enough say in what she or he does with her or his time.

At the Richard Aldworth Community School on the south side of Basingstoke, headteacher Mike Ward believes he has solved these problems. For the past four years his school has been joint-funding their school nurse, Liz Narracott, with the local health authority.

A mainstream comprehensive with 920 pupils, Richard Aldworth has a small unit for l0 or so children with physical disabilities, and a small unit for hearing-impaired children. Already in discussion with the health authority about the setting-up of the unit for children with physical disabilities, Mike Ward was able to negotiate a deal whereby the school pays half of a Pounds 16,000 salary and gets a full-time qualified nurse.

"Ostensibly the children with physical disabilities were the reason for getting Liz in," says Ward. "I just didn't anticipate the ways in which the whole school has benefited. We've got a counselling service we didn't have before and, if a child has an accident, we've got an expert on hand who knows all the staff at the local hospital. Liz is able to get directly involved in classroom work - particularly in sex education and she's given us valuable curricula input."

So successful has the experiment proved, that the health authority has extended the same arrangement to four other schools in the area and is in talks with two more.

* For further advice, contact your local health authority or trust

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