School-aged years high impact area 2: Improving health behaviours and reducing risk

Question 1

Sexual health

Accepted Answer

The under-18 conception rates has fallen by 60% since 1998 with the rate at its lowest level since 1969. Yet further progress is needed to narrow inequalities between areas and individual young people. There is a 7-fold variation in the under-18 conception rate between local authorities. Sixty per cent of areas have at least one ward with a rate significantly higher than the national average for England and young women who have experienced living in care are 3 times more likely to be a parent before 18.

However, significant differences in rates between local authorities and inequalities between wards remain. England’s teenage birth rate remains high in comparison with other western European countries and more needs to be done to sustain and accelerate progress. Despite improvements, the outcomes for young parents and their children are still disproportionately poor, with higher rates of low birthweight, postnatal depression and poor mental health for up to 3 years after birth. Chlamydia is the most frequent sexually transmitted infection diagnosis, followed by genital warts and gonorrhoea.

Child sexual exploitation or child sexual abuse

It was estimated that in 2011 that approximately 60,000 girls aged 0 to 14 were born to mothers with female genital mutilation (FGM) in England and Wales. It must therefore be considered whether these girls are also at risk of FGM as they grow up. An estimated 10,000 girls born overseas who are now living in England and Wales have FGM, and the NHS treated 106 girls aged under 18 with FGM between April 2015 and March 2016. A further 2,409 children and young people were victims of sexual exploitation by groups and gangs between August 2010 and October 2011.

Question 2

Alcohol and substance misuse

Accepted Answer

The proportion of children in the UK who drink alcohol remains well above the European average. We continue to rank among the countries with the highest levels of consumption among those who do drink, and British children are more likely to binge drink or get drunk compared to children in most other European countries. Some young people are particularly vulnerable to misusing drugs and alcohol, including young offenders, those with poor mental and emotional health, and those experiencing child sexual exploitation and abuse.

Smoking and vaping

Smoking rates among young people in England continue to decline, however latest data show that 16% of pupils aged 11 to 15 have smoked, with 5% classed as current smokers. Experimenting with tobacco use is a key risk factor for future regular smoking. Concerns have been expressed that e-cigarettes may be acting as a route into smoking for young people, however there is so far no evidence that this is the case.

Experimentation with e-cigarettes is fairly common among young people, with 15.4% of 11 to 18 year olds in Great Britain having tried them. However regular use is very low, with only 1.6% using e-cigarettes at least weekly and a further 3.3% using them less than weekly. Use is largely confined to current or ex-smokers.

Poverty and inequalities

Children and young people (10 to 14 years old) living in deprived areas are 3.7 times more likely to be killed or seriously injured on the roads.

Child criminal exploitation: county lines

More than 10,000 Child in Need Assessments in England recorded gang involvement as factoring in the child’s life. It is estimated there are 30,000 children who are involved in gang activity, 2019.

Children as young as 12 years old have been exploited or moved by gangs to courier drugs out of their local area. However, the most common age range for child criminal exploitation by county lines gangs is 15 to 16 years old.

Exploitation by county lines gangs correlates with poverty, family breakdown and intervention by children’s services, being looked after, going missing frequently, behavioural and developmental disorders, and exclusion from mainstream schooling. Gangs also target children who have a history of criminal involvement or where their parents are drug users and already engaged with or exploited by county lines criminals.

Question 3

Health behaviours and lifestyle

Accepted Answer

Accident prevention

School nurses and other professionals have an important role to play in reducing unintentional injuries. There are significant health inequalities related to child injury, with children and young people who live in more deprived areas at greater risk than children from more affluent areas.

There would be fewer serious or fatal injuries to pedestrians annually, and fewer serious or fatal injuries to cyclists, if all children and young people had a risk of injury as low as those in the least deprived areas.

Data from 2012 to 2016 highlights that the rates of children and young people killed or seriously injured in road traffic collisions have fallen by 16%. Over the 5 year period this equates to a total of 32,607 children and young people killed or seriously injured – around 5,500 fewer than in previous analysis, suggesting an average of 1,100 fewer per year.

Preventing unintentional injuries in the home and on the roads requires a whole system approach that maximises the contribution of all staff working with children and young people and their families.

Physical activity

Adolescence and early adulthood is a time when life-long health behaviours are set in place. Physical activity declines across adolescence – 1 in 5 school pupils aged 11 to 15 are obese and teenagers consume on average 8 times the recommended daily sugar allowance.

Physical inactivity is responsible for 1 in 6 UK deaths (equal to smoking) and is estimated to cost the UK £7.4 billion annually (including £0.9 billion to the NHS alone). The number of children meeting the recommended amount of physical activity for healthy development and to maintain a healthy weight (60 minutes a day) drops by 40% as they move through primary school.

All children have access to the universal Healthy Child Programme 5 to 19, which is led by school nurses but delivered in partnership with others. There are some children and young people who are particularly vulnerable, and require additional support.

Question 4

The role of school nurses

Accepted Answer

School nurses and their teams are in a unique position to build trusting and enduring professional relationships with children and young people throughout their time in education to enable them to become confident and healthy adults. It is essential that young people in secondary education or college can have access to safe, confidential and accessible services when they need health support and advice.

Working with parents and families and partner agencies, school nurses identify the most appropriate level of support and intervention for individual and population needs. Although school nurses provide leadership, they will need to work with partners to deliver a comprehensive programme of evidence-based interventions.

School nurses and their teams provide a crucial interface between children, young people, families, communities and schools. They have a skillset which can support holistic assessment of the health and wellbeing needs of children and young people. They provide health promotion, prevention and early intervention approaches to support individual, community and population health needs.

Using their skills with the wider health and care system and their trusted relationships with other partners helps to support and enable place based and whole school action to address health inequalities. Their involvement in delivering evidence-based interventions including HPV and other immunisation programmes in the teenage years, also provide opportunities for health promotion, Making Every Contact Count to support behaviour change.

School nurses deliver care in the most appropriate setting for the local community, using the principles of the You’re Welcome Quality Criteria. This includes using technology to improve access and support for children, young people and families.

Question 5

Healthy Child Programme

Accepted Answer

The Healthy Child Programme offers every family a programme of screening tests, immunisations, developmental reviews, information and guidance to support parenting and healthy choices – all services that children and families need to receive if they are to achieve their optimum health and wellbeing.

Universal

The Healthy Child Programme is universal in reach. It sets out a range of public health support in local places to build healthy communities and to reduce inequalities. It also includes a schedule of interventions, which range from services for all through extra help to intensive support.

Personalised

The Healthy Child Programme is personalised in response. All services and interventions need to be personalised to respond to the needs of families across time. For many families this will be met by the universal offer. More targeted, intensive or specialised support and evidence-based interventions should be provided early to meet ‘predicted, assessed and expressed need’ and improve outcomes.

Question 6

Improving health and wellbeing

Accepted Answer

The high impact areas will focus on interventions at the following levels and will use a place-based approach:

individual and family
community
population

The place-based approach offers opportunities to help meet the challenges public health and the health and social care system face. This impacts on the whole community and aims to address issues that exist at the community level, such as poor housing, social isolation, poor or fragmented services, and duplication or gaps in service provision. School nurses as leaders in public health and of the Healthy Child Programme (5 to 19) are well placed to support families and communities to engage in this approach. They are essential to the leadership and delivery of integrated services for individuals, communities and population to provide RightCare that maximises place-based systems of care.

Individual and family

School nurses can carry out health assessments as part of the Healthy Child Programme (5 to 19) and, when appropriate, a structured assessment to identify risk-taking behaviours. They have a role in raising awareness and supporting children to keep safe and provide an accessible, confidential service that is conducive to building a rapport and trust between practitioners and children and young people.

School nurses can raise awareness of risk-taking behaviours with children and young people, carers, families and other professionals, particularly within the school community. This may be opportunistic or planned and will be in partnership with specialist services. They can support children and young people to improve resilience by building skills and promoting good mental health and wellbeing, as well as focusing on mental illness and diagnosis.

School nursing teams are ideally placed to identify children and young people who may require additional support such as children with disabilities; children in care; children who are more likely to experience frequent moves of home and school; young carers; lesbian, gay, bisexual or transgender children; children with gender issues; or children with a parent or parents suffering from mental health problems. School nurses can make a vital contribution to developing resilience and good mental health and emotional wellbeing.

School nurses can help children and young people to build knowledge and skills about their health and wellbeing to provide them with skills for life. Health literacy has a vital role for young people who are at a life stage where they are increasing their independence and becoming less reliant on parents and carers. It empowers them to make decisions about their own health and to access and use health services appropriately. This includes measures to reduce sexually transmitted infections and to use antibiotics appropriately.

Community

School nurses can lead and support delivery of preventative programmes for children and young people through the Healthy Child Programme (5 to 19). They have a key role in educating children, including providing support and advice on risk-taking behaviours, for example smoking or substance abuse.

They can also raise awareness of risk-taking behaviours with children and young people, families and carers, and other professionals, particularly within the school community. This may be opportunistic or planned, and will be in partnership with specialist services, including substance misuse, alcohol, sexual health, sexually transmitted infections, accident prevention and links to safety schemes and wider community resources.

The role extends to support development and delivery of relationships, sex and health education (RSHE) in education in schools and other settings. They can support schools implement the RSHE guidance. A key requirement of the guidance is to ensure all pupils are aware of and know how to access local services.

School nursing teams also have a role in:

raising awareness and supporting children to keep safe. School nurses provide an accessible, confidential school nursing service that is conducive to building a rapport and trust between practitioners and children and young people
providing health leadership, working with education staff and other partners and young people to develop a whole school approach to safeguarding children, influencing effective delivery of the Relationships, Sex and Health Education curriculum

Population

School nurses can make links and work with the local authorities and other agencies on wider determinants of health, such as planning, licensing, law enforcement, and health and safety. Their leadership can support the development of local partnerships and pathways aimed at keeping children and young people safe in the community. School nurses can play a vital role in primary and secondary prevention of various issues, for example, working with community leaders and police to address child sexual exploitation through the provision of sexual and reproductive health services health community clinics and joined up responses to alcohol-related crime.

As leaders and key deliverers of the Healthy Child Programme (5 to 19), school nurses have a key role to play in establishing good working relationships with all local partners. They can influence the alignment of wider prevention and community-based programmes and services which promote health and wellbeing, for example sexual health and contraception, reducing obesity and smoking cessation. This can provide a whole-systems approach to prevention and support the provision of early universal access to key information for tackling health issues.

School nurses can work with local authorities and NHS commissioners to ensure that clear care pathways exist between school nursing teams and key services that young people access. These might include mental health and wellbeing services, substance misuse and sexual or reproductive health services, child sexual exploitation, child sexual abuse, Family Nurse Partnership and teenage parent support, substance misuse prevention and oral health services. Ensuring all pupils are aware of and know how to access local services is a requirement of the new guidance.

School nurses act as advocates for children and young people at a strategic level, working in partnership with other agencies, developing approaches, pathways and interventions that promote resilience. Through their advocacy role, school nurses can promote the voice of the child, ensuring children and young people are listened to – particularly those who may have additional needs. They can also contribute to the development and design of changes to service delivery.

In addition, school nurses can also work with local authorities to develop injury prevention strategies. Many injuries are preventable and action can save lives. Once effective action to prevent injury has commenced, results can often be seen quickly.

Question 7

Using evidence to support delivery

Accepted Answer

A place-based, or community-centred, approach aims to develop local solutions. Such solutions draw on all the assets and resources of an area, integrating services and building resilience in communities so that people can take control of their health and wellbeing, and have more overall influence on the factors that underpin good health.

The All Our Health framework brings together resources and evidence that will help to support evidence based practice and service delivery, Making Every Contact Count and building on the specialist public health skills of school nurses.

Most health and care professionals focus on interventions which tend to be delivered on an individual basis, however health visitors and school nurses focus on individuals, families and community approaches. It is critical that all professionals consider the importance of population health as an approach that aims to improve physical and mental health outcomes, promote wellbeing and reduce health inequalities across an entire population.

Social prescribing complements such approaches, enabling public health nurses and other health and care professionals to refer people to a range of local, non-clinical services. School nurses recognise that children and young people’s health is determined primarily by a range of social, economic and environmental factors. Social prescribing seeks to address individuals needs in a holistic way, helping individuals to take greater control of their own health.

Question 8

Measures of success or outcome

Accepted Answer

High quality data, analysis tools and resources are available for all public health professionals to identify the health of the local population. This contributes to the decision-making process for the commissioning of services and plans to improve people’s health and reduce inequalities in their area. Outcome measures could include Public Health Outcomes Framework and NHS Outcomes Framework, child and maternal health profile indicators, measures of access, and service experience.

School nurses and wider stakeholders need to demonstrate impact and provide evidence of improved outcomes. This can be achieved by using local measures.

Access

Measures include:

number of young people who have access to the school nursing service
number of children and young people receiving an intervention from school nurse, including immunisations
number of children and young people who receive a health needs assessment from school nursing in accordance with the Healthy Child Programme (5 to 19)

Effective delivery

Measures include:

reduced social isolation and targeted support to meet local needs

Measuring impact

Measures include:

User experience

Measures include:

feedback from children, young people and families via the NHS Friends and Family Test, You’re Welcome quality criteria, local service surveys and local authority consultations

Other measures can be developed locally and could include local pathways and partnership approaches to supporting vulnerable children and young people. This could be, for example: referrals to young carers groups, engagement of previously non-compliant vulnerable children and young people with services for example school nursing led sexual health services, evidence based assessment tools, identification of young carers and unaccompanied asylum seeking children.

Question 9

Connection with other areas

Accepted Answer

The high-impact area documents have been developed to support delivery of the Healthy Child Programme and 5 to 19 agenda. They also highlight the link with a number of other interconnecting policy areas, for example childhood obesity, troubled families, mental health, drugs, immunisations, and social mobility. The importance of effective outcomes relies on strong partnership working between all partners in health (primary and secondary), local authorities including education services, and voluntary sector services.

Best Start in Life has been identified as a priority as part of Public Health England’s (PHE) 5-year strategy which runs from 2020 to 2025. Best Start in Life is a priority for government and as such is included in the Prevention Green Paper (Advancing our health: prevention in the 2020s).

Improving services for children and young people is part of the NHS Long Term Plan. The Child Digital Strategy includes a range of work which underpins these plans, including maternity and community data sets and implementation of the digital parent-child health record. A major contribution to achieving these ambitions and strategies is the modernisation of the Healthy Child Programme.

Collaborative working

Approaches to improving outcomes through collaborative working include:

Public Health Outcomes Framework indicator reported and benchmarked by PHE and local authorities
revised commissioning guidance service specification for ages 0 to 19
use of the high impact areas model and delivery of the Healthy Child Programme
information sharing agreements in place across all agencies
integrated commissioning and delivery of services
working with schools to support integrated planning, delivery and monitoring
information sharing from Joint Strategic Needs Assessment (including health data and information about families and communities) to identify and respond to joint priorities
information sharing (including health information about individuals and families) to identity and respond to safeguarding issues
demonstrating value for money and return on investment

Improvements

These include:

improved accessibility to services for vulnerable groups
improved engagement with children and young people and co-production of services to make them young people friendly
integrated IT systems and information sharing across agencies
development and use of integrated pathways
systematic collection of user experience – NHS Friends and Family Test and You’re Welcome
engagement with local authorities and consultations with young people and families to inform action
increased use of evidence-based interventions and links to other 5 to 19 performance indicators
improved partnerships between schools, GPs, Child and Adolescent Mental Health Services (CAMHS), oral health services, sexual health services, alcohol and drug services, secondary care, children, young people and families
consistent health and wellbeing messages and information for children, young people, parents and carers
early identification of strengths and risks of the child or young person, as well as young people not in education, employment or training
improved engagement of previously disengaged children and young people and those who disengage with treatment

Professional or partnership mobilisation

These include:

multi-agency training and supervision to identify risk factors and early signs of health and wellbeing issues
multi-agency training, working in partnership with young people to identify strengths and needs to inform a holistic assessment
multi-agency training in approaches for young people friendly services and interaction with children and young people
multi-agency training in evidence based early intervention and safeguarding practices
effective delivery of universal prevention and early intervention programmes
improved understanding of data within the Joint Strategic Needs Assessment and at the local Health and Wellbeing Board
integrated working of school nursing services with existing local authority arrangements to provide holistic or joined-up and improved services for young children, young people, parents and families – this includes effective joint working with specialist services, including alcohol and drug services, sexual health services, child sexual exploitation, mental health services and oral health services.
identification of skills and competencies to inform integrated working, workforce development and skill mix
increased integration and working with schools and community health and social care services to offer range of services and activities to promote health and wellbeing

Question 10

Associated tools and guidance

Accepted Answer

Policy

Building children and young people’s resilience in schools, PHE and UCL Institute of Health Equity, 2014

Children and Families Act 2014

Working Together to Safeguard Children, HM Government, 2018

Teenage Pregnancy Prevention Framework, PHE and Local Government Association (LGA), 2018 (updated 2019)

A Framework to support teenage mothers and young fathers, PHE and LGA, 2016 (updated 2019)

Antibiotic guardian

Child and Maternal Health, PHE

Child safety online: A practical guide for providers of social media and other services, UK Council for Child Internet Safety, 2015

e-Bug

ESPAD report 2015: Results from the European School Survey Project on Alcohol and Other Drugs, ESPAD, 2016

Heads or tails: What young people are telling us about SRE, Sex Education Forum, 2016

Improving support for young carers: Family-focussed approaches, DfE, 2011

Junior and family antibiotic guardian

Key data on young people, Association for Young People’s Health, 2019

Local action on health inequalities: Reducing the number of young people not in employment, education or training (NEET), PHE, 2014

Reducing antimicrobial resistance, e-Learning for Healthcare

Rise Above

The drug strategy 2017, Home Office, 2017

The role of school nurses in supporting young carers, Carers Trust, 2014

Young people: Substance misuse commissioning support pack 2018-19: Principles and indicators: Planning comprehensive interventions for young people, PHE, 2018

Guidance

Helping school nurses to tackle child sexual exploitation, Department of Health and Social Care (DHSC), 2015

Maximising the school nursing team contribution to the public health of school aged children: Guidance to support the commissioning of public health provision to school aged children 5 to 19, DHSC, 2014

Reducing unintentional injuries on the roads among children and young people under 25 years, PHE, 2018

Relationships and sex education (RSE) and health education. Statutory guidance, DfE, 2019

Relationships and sex education: contributing to the safeguarding, sexual & reproductive health of children and young people – what role can councillors play?,, PHE, LGA, RSE Hub and Sex Education Forum, 2018