Most health authorities in 1994 had still ignored guidance issued nearly 15 years ago to scrap routine medicals for all pupils at defined stages and replace them with selective examinations, a Scottish Office policy review on Health Services in Schools admitted recently.
Yet Tayside Health Board faced accusations by parents and councillors of cost cutting and discrimination when it laid out plans two years ago to screen pupils for medicals, undertaking examinations only where there was a clear need.
Two years later John Kemp, convener of Dundee's education committee, has given a cautious welcome to a pilot screening system started this term in two secondaries and their associated primaries by Dundee Healthcare Trust. "If it does not work I hope there is some way we can restore medicals for all pupils," Mr Kemp says.
Parents of children in primary 1 are asked to fill in a questionnaire and offered a "health interview" with the school nurse to discuss their child and ensure that the questionnaire has been fully understood. The child's previous record is checked.The nurse only refers a child to a medical if there is cause for concern or a gap in records.
As the Scottish Office review points out, school health services must adapt to the modern world where health visitors and GPs undertake extensive pre-school surveillance and where there is a clear need to identify and support increasing numbers of children with complex and special needs.
But opinion remains divided in the health profession. Lanarkshire Health Board still uses school medicals, not least as a means of evaluating "just how effective our pre-school surveillance has been", Charles Clark, a public health consultant, says. Dr Clark argues that since parents cannot be guaranteed to attend child clinics the universal medical is "the one real opportunity there is to examine all children. Its comprehensiveness is quite invaluable. I would have a lot of anxieties if it were stopped."
Yet the days of universality seem numbered. Routine medicals have been scrapped by Dumfries and Galloway, Fife and Edinburgh. Zoe Dunhill, clinical director of community child health for Edinburgh Sick Children's Trust, says: "The detection rate of diseases and impairments in these examinations was very low."
Tina Hill, community child health director of Fife Healthcare Trust, agrees. But universal medicals had one advantage to schools and parents, she points out. "They gave them the feel-good factor." They also give prominence to a service with a low profile.
"A lot of what we do is hidden work," Dr Dunhill says. An audit of parents' views on school health services two years ago revealed a belief that "we could do better".
The Scottish Office says that screening for medicals should take place when the child is aged five, 11 and 14. Psychological well-being should be assessed. There should be checks for height and weight, vision and hearing, and tooth decay, and continuous monitoring of pupils with special needs. A full school immunisation programme must also operate. Contracts with healthcare trusts which run school services should include liaison with education departments to promote health education, an area where provision is "not universal".
According to Dr Clark, that means "something will have to give". The review remains vague about paying for the new-look school provision, an omission noted by Martin Vallely, Edinburgh education department's professional services manager. Mr Vallely instances the increasing numbers of special needs pupils in all types of schools and comments: "The issue is how far can we address all needs with the resources available."
The review does not set out how tasks should be divided but makes the general point that "some duties currently carried out by the school doctor may be more appropriate for the school nurse".
That is in line with the expanding role of nurses throughout the health service. Yet in using the phrase "just nurses" one Tayside councillor revealed a common fear two years ago when plans for school nurses to give hearing and sight tests were being discussed.
The review emphasises adequate training. All Dundee school nurses, for example, have a specialist certificate. But training adds to healthcare trusts' costs, particularly as qualifications move towards degree and postgraduate status.