The health and safety of children in the classroom is at risk because the school health service is patchy and the relative responsibilities of nurses, teachers and parents are unclear, according to the first-ever survey of school nurses.
School nurses are taking on an increasingly sophisticated role and bigger workloads, especially in preventive health advice and identifying children with mental and behavioural problems. However, they are still striving to throw off the unglamorous "nit-nurse" image and tend to be a soft target for cuts.
There is no statutory requirement for a school nursing service, nor is there any statutory training requirement. Some schools have weekly health clinics. Others receive one visit from a nurse each half term.
The national survey of 500 school nurses by the Health Visitors' Association also shows that more than half of them are over 50 - which points to an imminent shortfall if retiring nurses are not replaced. Figures from the Royal College of Nursing show that the number of nurses entering school nurse training declined from 250 in 1991 to 85 in 1995.
Caseloads have increased - 24 per cent of the sample were responsible for more than 3,000 children - and almost half said their workload had increased by between 25 and 30 per cent over the past five years. But school nurses appear to welcome the fact that their role has evolved from screening pupils to health education, dealing with children with special needs and running drop-in clinics.
Most nurses carry out health interviews as well as hearing and vision checks without a doctor present, but most are not allowed to refer children to a paediatrician. Most reported a dramatic increase in mental and behavioural problems in children since they began their careers. Just over a third are still carrying out head-lice checks, though most would prefer not to.
One worrying finding is that 12 per cent said that BCG vaccinations against tuberculosis were not given in their district, despite worldwide concern about the resurgence of this disease. A larger number said that the vaccination was not automatically given.
Sue Botes, professional officer at the HVA, said that the role of school nurses needs to be clarified and standardised: "We need to decide who is responsible for children's physical wellbeing while they are in school. Teachers are not medically trained and do not have the time to be constantly on the outlook for difficulties."
New guidelines published by the Department of Health last week state that extensive health screening at school is unnecessary because problems should be picked up before the child starts school. The school health service should shift from screening to health promotion.
School Nursing: Here today for tomorrow, Pounds 3.95 from the Health Visitors' Association, 50 Southwark Street, London SE1