Guidance

School-aged years high impact area 5: Supporting additional and complex health needs

Updated 19 May 2021

Applies to England

In 2019, 1 in 4 (23%) of 11 to 15 year olds reported they had a long-term illness or disability, with asthma counting for over half the cases (Association for Young People’s Health (AYPH), 2019). All children and young people have a right to achieve their full potential. It is important to ensure children and young people with additional or complex health needs are supported to achieve the best possible outcomes and can engage with learning, whilst maintaining their health and social wellbeing.

Some children with long-term conditions require support or medication during the school day to ensure that they remain well. A child or young person’s educational attainment can be affected by school absences due to hospitalisation, frequent appointments or lack of support to promote attendance. If they are not adequately supported this may impact on the child’s health, social and educational outcomes such as:

• school attendance
• emotional health and wellbeing, for example having low self-esteem or experiencing bullying
• ability to access the full curriculum, for example physical education, see Supporting pupils with medical conditions at school

Children and young people with additional or complex health needs often require additional support to ensure a seamless transition into school and so that they feel supported to learn within an education setting.

Whilst most children with complex and additional health needs will have their needs met within mainstream education settings, some will need additional support from specialist services. Health, education and social care should work together with parents or carers to agree ambitious outcomes for identified children, set clear individual progress targets and be clear in their planning about how resources are going to support and help the child and family reach their targets or aspirations. Parents or carers will be fully involved in discussions about their child’s progress and reviews of the provision needed to achieve the agreed outcomes.

These children and young people may require an Education, Health and Care Plan needs assessment in order for the local authority to decide whether it is necessary for it to make provision in accordance with the Special Educational Needs and Disability (SEND) Code of Practice 0 to 25 Years.

The process for assessment and planning of an Education, Health and Care (EHC) plan should be joined up, outcomes-focused and delivered in partnership with parents or carers. It is agreed and completed within a maximum of 20 weeks. However, there are times when a child has speech and language delay or behavioural problems, which are not considered a special educational need or disability and therefore do not warrant an EHC plan.

Access to services needs to be timely and responsive to individual and family needs. School nursing teams need to work collaboratively with other health professionals, including GPs, oral health services, community children’s nurses, community paediatricians and wider stakeholders, for example schools, youth services and social care. When supporting vulnerable and isolated children, it is important to ensure services are delivered in locations and at times that are appropriate to their needs. This may include home visits or use of community locations other than schools. It is important to work within national and local safeguarding pathways and arrangements, ensuring that the voice of the child is considered. School nurses’ unique position means they can advocate for vulnerable children and young people, including those with complex and additional needs, who may not be able to easily verbalise their concerns or needs.

Parents or carers of children with long-term health needs may have concerns about how well their child will be cared for during the school day. Governing bodies of all schools and academies have a statutory duty to ensure that there are arrangements in place to support pupils with health needs.

Parents of children with health needs can often be concerned that their child’s health may deteriorate when they attend school. This is because pupils with long term and complex medical conditions may require ongoing support, medicines or care while at school to help them manage their condition and keep them well. Long term absences due to health problems can also affect children’s educational attainment, impact on their ability to integrate with their peers and affect their general wellbeing and emotional health.

Children may be self-conscious about their condition and some may be bullied or develop emotional disorders such as anxiety or depression around their health needs. Short-term and frequent absences also need to be effectively managed and appropriate support put in place to limit the impact on the child’s educational attainment and emotional and general wellbeing. School nurses are responsible for notifying the school when a child has been identified as having a medical condition which will require support in school and, in some situations, may support staff in implementing a child’s individual healthcare plan and provide advice and liaison, for example on training.

Long-term conditions

Although young people aged between 10 to 24 generally have good physical health, many will experience a range of short-term physical health problems. Headaches, abdominal pain, muscular skeletal disorders, allergies, skin disorders and acne, coughs and respiratory infections are some of the common physical health problems for which young people seek medical advice. However, a significant minority will have long term chronic conditions or some kind of disability.

Management of these illnesses can be challenging, and the school nurse can play a crucial role advising and supporting schools to ensure the needs of children and young people are identified, met and effectively managed to limit the impact on the child’s educational attainment and emotional and general wellbeing.

Encouraging children and young people to feel confident in accessing health services is key to engaging and involving them in decisions about their health and wellbeing and care. You’re Welcome is a set of quality criteria for young people friendly health services. It provides a systematic framework to help commissioners and service providers to improve the suitability, accessibility, quality and safety of health services for young people.

The role of school nurses

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 and families, communities and schools having defined skills to 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.

Healthy Child Programme

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 families’ needs 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’ to improve outcomes.

Improving health and wellbeing

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, or 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 support children and young people aged 5 to 25 who have complex and long-term health needs. School nurses can advocate for the child, young person, and parent or carer to ensure that the child’s voice is heard, especially if they have communication difficulties or are unable to articulate for themselves.

School nurses can identify children and young people who may require additional support or who would benefit from signposting or referrals to more specialist services such as children and young people’s mental health services, oral health services, contraceptive and sexual health services or substance misuse services.

School nurses can signpost and offer information and support, liaise with key professionals involved in the child or young person’s care and support school staff around training. School nurses work closely with community children’s nurses and community paediatricians.

School nurses can educate families and children about hygiene, particularly when children or family members have an illness or infection. They can play a vital role in educating families and children about appropriate use of antibiotics and self-care.

Transition to secondary school or college can be a period of high anxiety for young people with additional or complex health needs. Working closely with the multidisciplinary team, school nurses can offer support to young people to manage their health condition and medication within mainstream school. Identifying concerns early, putting a health plan in place including regular reviews, and offering support through ongoing health drop-ins can help smooth periods of transition.

School nurses can support young people with complex health needs to access universal health advice, for example sexual health services. The focus on medical conditions may conceal the normal adolescent development needs.

Community

School nurses lead the Healthy Child Programme (5 to 19) and have good awareness of local services available. They can provide help and support within communities to enable access to services. This supports the reach of services and the activities they provide. School nurses can work with communities to recognise strengths and assets, build relationships and to work together to develop solutions to address local issues.

Strong partnership working is required to ensure seamless support is provided. School nursing services are well placed to lead and co-ordinate support effectively. They can support schools to manage the health and wellbeing of their pupils. This includes delivery of health-related training, advice and development of school policies, for example, medicines management, whole school approach to health and wellbeing and supporting the delivery of school-based supervised tooth brushing and fluoride varnish programmes.

School nurses can also support delivery of statutory relationships and sex education (RSE) and health education guidance in all schools, including Special Schools.

Population

School nurses lead the Healthy Child Programme (5 to 19) and provide leadership at a strategic level to contribute to the development and improvement of policies, pathways and strategies to support delivery of high quality, evidence based, consistent care for children, young people and families for transition into and preparation for adulthood.

Clear multi-agency infrastructure and locally agreed assessment frameworks will provide the opportunity to jointly assess individual and family needs, whilst offering clarity around multi-agency partners’ roles and responsibilities. Robust leadership and accountability will support delivery of tailored services as part of agreed local arrangements.

School nurses can support the rights of all children and young people to be heard, to have access to appropriate healthcare and education and to fulfil their potential. This includes involving children and young people or their representatives in the development of services for those with complex and additional health and wellbeing needs and ensuring information is available for all in the most appropriate format, including:

• face-to-face
• electronic
• print
• easy to read
• pictorial

Using evidence to support delivery

A place-based, or community-centred, approach aims to develop local solutions that 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 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 communities’ 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 and seeks to address individuals needs in a holistic way, taking greater control of their own health.

Measures of success or outcomes

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 future 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 evidence of improved outcomes. This can be achieved by using the local measures.

Access

Measures include:

• number of children with complex or additional health needs who have access to school nursing services
• evidence of local multi-agency pathways setting out good practice for identification, assessment, and support for children and young people aged 5 to 19 with complex and additional health needs or disability

Effective delivery

Measures include reduced social isolation and targeted support to meet local needs.

Measuring impact

Measures include:

• reduction in school absences and Department for Education (DfE) statistics on pupil absence total difficulties scores for all children in care aged between 5 and 16 at the date of their latest assessment, who have been in care for at least 12 months on 31 March, available in the Public Health Outcomes Framework
• estimated number of 16 to 17year olds not in education, employment or training, or whose activity is not known, available in the Public Health Outcomes Framework
• Under 18 and under 16 conception rates
• number of conceptions that occur to women aged 18 or under that result in either one or more live or still births or a legal abortion under the Abortion Act 1967, quarterly and annual reporting by the Office of National Statistics and in the Public Health Outcomes Framework
• number of finished admission episodes in children aged between 10 to 24 years where the main cause is intentional self-harm, available in Child Health Profiles
• number of hospital admissions in children aged between 10 and 14 years where the main cause is intentional self-harm, available in Young Peoples Profiles
• hospital admissions in children aged between 15 and 19 years where the main cause is intentional self-harm, available in Young Peoples Profiles
• number of finished and unfinished continuous inpatient spells, excluding transfers, for patients aged under 19 with an emergency admission and where asthma, diabetes or epilepsy were the primary diagnosis, available in NHS Outcomes Framework
• number of Education, Health and Care Plans in place

User experience

Measures include:

• feedback about service delivery from children, young people and families via the NHS Friends and Family Test, You’re Welcome and local service surveys
• engagement exercises with children and young people carried out by the local authority and school

Other measures can be developed locally and could include local pathways and partnership approaches to supporting children with additional and complex health needs, for example referrals to specialist services or to support groups, engagement of previously non-compliant/vulnerable children and young people with medication or treatment.

Connection with other areas

The high-impact area documents have been developed to support delivery of the Healthy Child Programme and 5 to 19 agenda, and to highlight the link with a number of other interconnecting policy areas, for example childhood obesity, Troubled Families, mental health, Drug Strategy and immunisation, Social Mobility Programme. The importance of effective outcomes relies on strong partnership working between all partners in health (primary and secondary), local authority including education services, and voluntary sector services.

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

Improving services for children and young people is part of the NHS Long Term Plan. The Child Digital Strategy and Maternity Programme is currently developing and implementing infrastructure to improve access and timeliness of data with the aim to know where every child is and how well they are. This includes the development and implementation of a Digital Parent Child Health Record This programme supports the ambitions and 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 authority
• SEND designated medical and or clinical officer - understanding roles and responsibilities for seamless provision of care outlined in Special Educational Needs and Disability (SEND) code of practice
• information sharing agreements in place across all agencies
• integrated commissioning of services to improve health and wellbeing outcomes
• partnership working with schools to support integrated planning, delivery, monitoring and review
• information sharing from Joint Strategic Needs Assessments (including health data and information about families and communities) to identify and respond to joint priorities
• understanding roles and responsibilities for seamless provision of care outlined in the SEND code of practice
• demonstrate value for money and return on investment

Improvements

These include:

• improved accessibility for vulnerable groups
• integrated IT systems and information sharing across agencies
• development and use of integrated pathways
• systematic collection of user experience, for example, NHS Friends and Family Test and You’re Welcome quality criteria, engagement with children and young people carried out by local authority to inform action and co-production with children and young people to deliver ‘young people friendly’ services
• increased use of evidence-based interventions and links to other early years performance indicators
• improved partnership working, for example, schools, children’s social services, GPs, oral health services, children and young people
• consistent information for children, young people, parents and carers
• ensuring individual care plans are providing effective early interventions
• improved engagement of previously non-compliant children and young people

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 in approach for discussions with children and young people to obtain information
• 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, used to inform priorities in the Joint Health and Wellbeing Strategy and understanding at the local Health and Wellbeing Board of who holds delivery to account
• integrated working of school nursing services with existing local authority arrangements to provide a holistic or joined up and improved service for children, young people and families. This includes effective joint working with specialist substance misuse services, oral health services, mental health, sexual health services and speech and language services
• identification of skills and competencies of school nursing teams to inform integrated working and skill mix
• increased integration and working with schools to offer a range of services and activities to promote health and wellbeing

Associated tools and guidance

Policy

Delivering better oral health: An evidence-based toolkit for protection, PHE, 2014

Children and Families Act 2014

Health Matters: child dental health, PHE, 2017

Improving oral health: An evidence-informed toolkit for local authorities, PHE, 2014

Working Together to Safeguard Children, 2018

Review into support for children with Special Educational Needs, 2019

Research

Child and Maternal Health, PHE

Conception to Age 2: The age of opportunity, Wave Trust, 2013

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

TAC interconnections

Working Together to Safeguard Children, DfE, 2015

Guidance

Complete routine immunisation schedule: Immunisation for health professional and immunisation practitioners, PHE, 2019

Getting it right for children, young people and families: health services, Department of Health and Social Care (DHSC), 2012

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 to19, DHSC, 2019

Guidance for health services for children and young people with Special Educational Needs and Disability (SEND), NHS England, 2018

Commissioning for transition to adult services for young people with Special Educational and Disability (SEND), NHS England, 2018

Relationships, Sex and health education. Statutory guidance, DfE, 2019

Long-term conditions

An Ordinary Life, Foundation for People with Learning Disabilities

Building the right support: A national plan to develop community services and close inpatient facilities for people with a learning disability and/or autism who display behaviour that challenges, including those with a mental health condition, NHS England 2015

Contact – For families with disabled children

Council for Disabled Children

Developing Key Working, Council for Disabled Children, 2013

Disability matters

Disability matters, e-Learning for Healthcare

Managing children with health care needs: delegation of clinical procedures, training, accountability and governance issues, Royal College of Nursing, 2012

National Network of Parent Carer Forums, Council for Disabled Children

No child with cancer left out, Clic Sargent, 2012

Providing support for children and young people with health needs in schools, Royal College of Nursing and Unison

SEND delivery support, DfE and DHSC

Support and Aspirations: A new approach to special Educational needs and disabilities Report, Department of Education, 2012

Supporting people with a learning disability and/or autism who display behaviour that challenges, including those with a mental health condition, Local Government Association, Association of Directors of Adult Social Services and NHS England, 2015

Supporting pupils at school with medical conditions, DfE, 2015

SEND Code of Practice 0 to 25 years, DHSC and DfE

SEND: Guide for health professionals, DfE and Department for Health and Social Care, 2016

SEND: Managing the 2014 changes to the system, DfE, 2015

The determinants of health inequalities experienced by children with learning disabilities, PHE, 2015

The Special Educational Needs and Disability regulations, 2014

Lifestyle

Alcohol, drugs and tobacco use Joint Strategic Needs Assessment support pack, PHE, 2014

NICE guidance

Oral health, Local authorities and partners, NICE guideline [PH55], 2014

Oral health promotion, general dental practice, NICE guideline [NG30], 2015