Guidance

Commissioning health visitors and school nurses for public health services for children aged 0 to 19

Updated 27 June 2023

Applies to England

Universal and targeted public health services provided by health visiting and school nursing teams are crucial to improving the health and wellbeing of all children and young people.

The foundations for virtually every aspect of human development including physical, intellectual and emotional, are established in early childhood. Sustaining this across the life course for school-aged children and young people is important to improve outcomes and reduce inequalities through universal provision and personalised response. There may be challenges within a child’s or a young person’s life and times when they need additional support (see No child left behind - a public health informed approach to improving outcomes for vulnerable children). Children in care, for example, experience more frequent moves of home and school so may face additional challenges (see the Children’s Commissioner stability index 2020).

Modernising the healthy child programme is intended to enable effective, focused services where additional needs are identified along with use of the latest evidence on effective practice and helping to bring councils, the NHS and partners together to achieve priority outcomes for children and families. Delivering this vision is reliant upon a wide range of partners working together and embracing change in order to:

• ensure high quality services for children, young people and families from actions to improve women’s health before, during and after pregnancy, see the Maternity Transformation Programme from NHS England

• give every child the best start in life - see information on:

  • childhood obesity
  • speech, language and communication
  • immunisation
• support school readiness and improve resilience for school-aged children
• support young people transitioning to adult services

National information supports the planning and design of local services responding to the population identified health needs. The importance of effective outcomes relies on strong collaborative partnerships with the child, family or carers and all partners in health (primary and secondary), local authority including early years services, and voluntary sector services.

Healthy child programme

Good health, wellbeing and resilience are vital for all our children now and for the future of society. There is good evidence about what is important to achieve this through improving children and young people’s public health. This is brought together in the national healthy child programme 0 to 19.

The 0 to 5 element of the healthy child programme is led by health visiting services and the 5 to 19 element is led by school nursing services. Together they provide place-based services and work in partnership with education and other providers where needed. The universal reach of the healthy child programme provides an invaluable opportunity from early in a child’s life to identify families that may need additional support and children who are at risk of poor outcomes.

The healthy child programme provides a framework to support collaborative work and more integrated delivery. It aims to:

• help parents, carers or guardians develop and sustain a strong bond with children
• support parents, carers or guardians in keeping children healthy and safe and reaching their full potential
• protect children from serious disease, through screening and immunisation
• reduce childhood obesity by promoting healthy eating and physical activity
• promote oral health
• support resilience and positive maternal and family mental health
• support the development of healthy relationships and good sexual and reproductive health
• identify health and wellbeing issues early, so support and early interventions can be provided in a timely manner
• make sure children are prepared for and supported in all childcare, early years and education settings and are especially supported to be ‘ready to learn at 2 and ready for school by 5’

Being ready for school is assessed as every child reaching a level of development which enables them to:

• communicate their needs and have good vocabulary
• become independent in eating, getting dressed and going to the toilet
• take turns, sit still and listen and play
• socialise with peers, form friendships and separate from parents
• have good physical health, including dental health
• be well nourished and within the healthy weight for height range
• have protection against vaccine-preventable infectious diseases, having received all childhood immunisations

It also involves:

• continued support through school age years to help every child to thrive and gain maximum benefit from education, driving high educational achievement
• identifying and helping children, young people and families with problems that might affect their chances later in life, including building resilience to cope with the pressures of life

Commissioning responsibilities

Under the terms of the Health and Social Care Act 2012, upper tier local authorities are responsible for improving the health of their local population. Local authorities are key commissioners and hold an array of statutory duties for children, including:

• promoting the interests of children in the development of health and wellbeing strategies (joining up commissioning plans for clinical and public health services with social care and education to address identified local health and wellbeing needs)
• leading partners and the public to ensure children are safeguarded and their welfare promoted
• driving the high educational achievement of all children
• leading, promoting and creating opportunities for co-operation with partners and parents or carers to improve the wellbeing of young people
• safeguarding and promoting the welfare of looked after children
• providing or commissioning oral health improvement programmes and oral health surveys to improve the health and wellbeing of children and young people (see the NHS Bodies and Local Authorities (Partnership Arrangements, Care Trusts, Public Health and Local Healthwatch) Regulations 2012 (statutory instrument SI3094)

Public health services

Regulation requires all families with babies to be offered 5 mandated health visitor reviews before their child reaches 2 and a half years old.

The early years health reviews are offered to all families with a child aged 0 to 5 years. However, this is not the extent of the health visiting service offer for families who may also require additional support from the health visiting team, for example a nursery nurse. There are no mandated reviews for school aged children. However, there are opportunities to develop a framework of reviews based on evidence, intelligence, professional judgement and service user voice which provides opportunities to review health and wellbeing needs, support behaviour change and influence outcomes. This presents opportunities for bringing together a robust approach for improving outcomes for children and young people across both health and local authority led services for children and young people aged 0 to 19.

Public health services commissioned by local authorities form part of the ‘whole system’ of support for children and young people’s health and wellbeing. Local authorities are well placed to ensure integrated commissioning and delivery with a wide range of stakeholders who provide support for physical and mental health and wellbeing, including the NHS and the voluntary and community sector, schools and colleges. Local commissioners should also consider the links and interface with screening programmes, mental health, sexual health, smoking, substance misuse and oral health services.

The core public health offer for all children includes:

• child health surveillance (including infant physical examination) and development reviews

• child health protection and screening

• information, advice and support for children, young people and families or carers

• early intervention and targeted support for families with additional needs

• health promotion and prevention by the multiddisciplinary team

• defined support in early years and education settings for children with additional and complex health needs

• additional or targeted public health nursing support as identified in the joint strategic needs assessment, for example, support for children in care, young carers, or children of military families

This guidance is based on a public health pathway for children and young people aged 0 to 19. Local authorities may also wish to consider the transition to adulthood, especially for young people who are vulnerable or needing additional support, including the interface with services for young people aged 16 to 25 in line with the NHS Long Term Plan ambitions for 0 to 25 years.

Health visiting and school nursing services (public health nursing workforce)

Health visitors and school nurses are specialist public health nurses (SCPHNs). A SCPHN is a registered nurse or midwife who has undertaken a year’s further post-registration training in child health, health promotion, public health and education. Health visitors and school nurses are registered on Part 3 of the Nursing and Midwifery Council Register as a specialist community public health nurse. Health visitors lead the 0 to 5 element of the healthy child programme and school nurses lead the 5 to 19 element of the healthy child programme. Health visitors visit families in their own home from the antenatal period up to school entry; the service is also delivered in several settings including families’ own homes, local community or primary care settings. School nursing services work with children and young people (5 to 19), both in and out of school settings for example through digital and other virtual support.

While both services should be led by a registered SCPHN, the skill mix within the team should be led by local needs and underpinned by a robust workforce plan. The team will consist of a skill mix including community staff nurses and nursery nurses. Health visitors and school nurses utilise their clinical judgement and public health expertise in identifying issues early, determining potential risk, and providing early intervention to prevent issues escalating. Utilising the specialist public health nurse skills is cost effective and yields benefits for parents, children and young people including continuity of care and undertaking a ‘navigating’ role supporting families through the health and social care system. Utilising the right skill set, at the right time, supports effective signposting and early intervention preventing issues escalating. To deliver the best possible service these staff require timely, accurate information at the point of care to plan and deliver and utilise their expertise.

Public health nursing services provide universal support and due to their close relationships with families or carers and community settings, including early years and education settings, health visitors and school nurses are key in supporting the local authority area’s early help system, which encompasses early intervention and the Supporting Families Programme or local equivalent.

Every family should be offered an evidence-based intervention programme consisting of screening tests, immunisations, developmental reviews and 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.

A range of public health inputs in local places are needed to build healthy communities for families and children and to reduce inequalities. The schedule of interventions provides information for all through extra help to intensive support.

All services and interventions need to be personalised to respond to families’ needs across time. For most families most of this will be met by the universal offer.

Outcomes

Health visitors and school nurses can use evidence and data to inform the commissioning process and improve outcomes through the following 4 interacting processes.

1. Securing better outcomes (plan)

Assess current position by:

• understanding the question or hypothesis

• engaging with service users

• defining what is needed

• reflecting on current practice

• defining priorities

2. Evidence into action (do)

Move from planning to action by:

• collecting and analysing data

• understanding population health needs

• determining best practice

• reviewing current service provision

3. Improving access (study)

Determine and identify what works and doesn’t work by:

• summarising the learning and agreeing outcomes

• engaging with service users

• developing plans for service development

4. Desired outcome (act)

Provide direction and lead change by:

• taking effective decisions

• collecting, analysing and reporting data

• evaluating and measuring impact

See ‘Appendix 3: measuring performance and outcomes’ for more detail.

Regulation and employer issues

All health visitor and school nursing services must be registered with the Care Quality Commission (CQC). This is a legal requirement as defined by the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The current commissioning arrangements have given rise to new ways of working and employment models. Public health nursing workforce: guidance for employers supports employers of health visiting and school nursing teams to work safely and effectively.

The guidance aims to help employers support an effective workforce to sustain high quality outcomes for children, young people, families, carers and local communities. It complements the Local Government Association Standards for employers of public health teams in England and addresses specific employment issues relating to health visitors and school nurses.

Health visitors, school nurses and their teams must meet the legal requirement for professional registration and revalidation. This must be in line with statutory requirements for practice issued by the Nursing and Midwifery Council (NMC) on revalidation requirements.

The service model

The service model is based on 4 levels of service depending on individual and family need:

• community
• universal
• targeted
• specialist

The use of community-based assets is central to the universal offer, where health visitors and school nurses are well placed to identify and signpost to local community support. Contact points or universal health and wellbeing reviews can be utilised to identify needs and to develop a support offer or signpost to specialist services if required.

The high impact areas have been developed to improve outcomes for children, young people and families. They are based on evidence of where these services can have significant impact for all children, young people and families and especially those needing more support.

A bundle of indicators is available to measure performance and outcomes, for example through the Community Services Data Set (CSDS).

Public health profiles are available, including regional profiles for Child and maternal health. Local authorities may wish to consider how their commissioning strategies can be directed to make an impact in these areas.

Early years high impact areas support include:

• transition to parenthood and the early weeks
• maternal and infant mental health
• breastfeeding (initiation and duration)
• healthy weight and healthy nutrition
• health literacy
• reducing accidents and minor illnesses
• health, wellbeing and development (ready to learn, narrowing the ‘word gap’)

School-aged high impact areas build on early identification of children in need of support and focus on key priority areas, and include support for:

• resilience and wellbeing
• health behaviours and reducing risk taking
• healthy lifestyles
• vulnerable young people and improving health inequalities
• complex and additional health and wellbeing needs
• self-care and improving health literacy

This guidance sets out the key components local authorities may wish to consider as part of their service specification for health visiting and school nursing services to lead and deliver the healthy child programme.

A needs-led approach

Health visitors and school nurses, as public health nurses, use strength-based approaches, building non-dependent relationships to enable efficient working with children, young people and families to support behaviour change, promote health protection and to keep children safe. This is the only workforce that can engage with all families in their own homes as well as other community settings. This is essential for early identification and interventions to mitigate problems worsening in the future, thus contributing to demand management in other service areas.

Interventions and support should be needs-led and tailored to meet individuals and families. There is a connectivity and fluidity between the level of support: in other words, the support required by most families and children or young people will predominantly be met through the universal offer. Health visitors and school nurses will utilise a needs assessment to determine targeted interventions which can be met within the services and where more specialist interventions will require referrals or clear signposting. While receiving specialist support, health visitors and school nurses will still provide the universal offer and work in partnership with other agencies.

Health visiting services

For ages 0 to 5, this guidance includes all infants and children resident in the local authority area. The scope of the guidance covers child health surveillance, health promotion, health protection, health improvement, support outlined in the healthy child programme 0 to 5, the health visiting service model and includes the role of the health visitor in:

• leading and delivering the 5 mandated health reviews
• delivering against the 6 high impact areas for early years
• continuity of family public healthcare from maternity to health visiting services
• contributing to safeguarding
• identifying and supporting vulnerable children and families
• addressing inequalities and contributing to the Supporting Families Programme or local equivalent

School nursing services

For ages 5 to19, this guidance covers maintained schools and academies, includes child health surveillance, health promotion, health protection, health improvement and support outlined in the healthy child programme 5 to 19, and includes the role of school nurses in:

• delivering against the 6 high impact areas for school-aged years
• supporting transition for school-aged children, for example transition between health visiting and school nursing, and into adult services
• supporting vulnerable children and those not in school, for example, children in care, young carers or young offenders
• supporting children who are home educated
• providing the support offered as part of the Supporting Families Programme refreshed health offer or local equivalent
• contributing to safeguarding

Services requiring aligned or joint commissioning

Local provision should be responsive to local needs, with integrated pathways that prevent children falling between the gaps in services and reduce inequalities in outcomes.

Local authority commissioners will want to work in partnership with NHS England teams, integrated care boards, local general practices, early years settings, schools, digital programmes for child health information and third sector organisations to increase both the health protection and public health input for children and young people. This will ensure that through co-ordinated commissioning, integrated local pathways for prevention, identification of needs, early intervention and specialist services are established.

Similarly, commissioning clinical support for children with additional health needs or long-term conditions and disabilities, including clinical support for enuresis or diabetes, lies with NHS England and integrated care boards, to ensure co-ordinated support across the life course. There will need to be joint working and collaboration with local authority commissioners and providers of health visiting and school nursing services.

There is also an opportunity to ensure interrelated issues such as substance misuse, sexual health, child sexual exploitation (CSE), child sexual abuse (CSA), domestic violence and abuse and mental health are more effectively commissioned to improve outcomes and improve use of local resources.

Arrangements for delivery of services for children and young people educated at home and in independent schools or further education settings are agreed and determined locally. However, this document could be used to inform commissioning of such services.

Local authorities may wish to consider the provision for young people aged 19 to 25, particularly vulnerable young people or those with long-term conditions, transitioning to adult services.

There is also scope to consider co-commissioning with schools and other partners to enhance the core school nursing service and improve access to local needs-led services. This may include a review or refresh of existing IT contracts.

Aims and objectives of the service

The aim of the service is to ensure that all children and young people receive the full- service offer of the healthy child programme 0 to 19. This includes universal reach for all children and offering services which are personalised to meet individual need and the early identification of additional and/or complex needs. This supports the specialist public health nursing contribution to improve local outcomes and reduce health inequalities for children and young people. Health visitors and school nurses demonstrate defined clinical and public health skills, professional judgment, autonomy and leadership.

At an individual level, the service includes:

• contributing to Better Births and the Maternity Transformation Programme
• early years healthy development review, The best start for life: a vision for the 1,001 critical days and the government’s progress report on delivering the vision published in February 2023
• providing expert advice to provide a secure environment to lay down the foundations for emotional resilience and good physical and mental health (see NHS help and advice Start for Life)
• ensuring early help and additional evidence-based preventive programmes will promote and protect health in an effort to reduce the risk of poor future health and wellbeing
• working with the Supporting Families Programme or local equivalent, and to ensure the health aspects meet the health needs of the whole family
• enabling children to be ready to learn at 2, ready for school by 5 to achieve the best possible educational outcomes throughout their school years

At a community level, the service includes:

• promoting optimal health and wellbeing and resilience through school aged years
• supporting families and young people to engage with their local community through education, training and employment opportunities
• supporting children, young people and families to navigate the health and social care services to ensure timely access and support
• working in partnership with local communities to build community capacity
• demonstrating population value best use of resources and outcomes
• ensuring effective use of community-based assets

At a population level, the service includes:

• developing effective partnerships and acting as advocate to support improvements in health and wellbeing of all children and families
• working in partnership with other professionals ensuring care and support helps to keep children and young people healthy and safe within their community
• providing a seamless, high quality, accessible and comprehensive service, promoting social inclusion and equality and respecting diversity

Service description

The health visiting and school nursing service (0 to 19) includes at an individual level:

• undertaking joint visits or consultations with other professionals in response to contact from children, young people and families, where appropriate
• building resilience, strength and protective factors to improve autonomy and self- efficacy based on best evidence of child and adolescent development, family context and support
• building personal and family responsibility, laying the foundation for an independent life

At a community level, the service includes:

• providing an integrated public health nursing service linked to primary and secondary care, early years, childcare and educational settings, by having locality teams and nominated leads known to the stakeholders, including a named health visiting team or school nursing team for every setting
• delivering the universal healthy child programme through assessment of need by appropriately qualified staff; health promotion; screening, immunisation and surveillance; engagement in health education programmes; involvement in key public health priority interventions and communities; interventions as specified within the healthy child programme

At a population level, the service includes:

• leading local delivery requirements, including focusing on the high impact areas
• delivering public health interventions using an asset-based approach to all children and young people
• ensuring services are responsive to local needs and delivered in a way that is accessible to all families
• keeping children and families safe
• working with the community, stakeholders and local commissioners to identify population health needs
• working with local authority and NHS commissioners to ensure that clear care pathways exist between health visiting and school nursing teams and key services that parents and young people access such as mental health and wellbeing services, substance misuse and sexual or reproductive health services, child sexual exploitation or or abuse, teenage pregnancy or substance misuse prevention, or oral health services
• ensuring there is a clear protocol for addressing the health needs of priority groups where the service will be maintained and preventing inconsistency
• ensuring and being able to evidence that the experience and involvement of families, carers, children and young people will be taken into account to inform service delivery and improvement
• championing and advocating culturally sensitive and non-discriminatory services that promote social inclusion, dignity and respect
• demonstrating the impact of the service provided through improved outcomes, reduced inequalities and service user feedback

Health visiting and school nursing are in a unique position to influence and work with the whole family in the interests of children on social, psychological and health choices and behaviours. School nurses are also well placed to affect health behaviour change when young people are developing independence, self-determination and autonomy. Health visitors and school nurses have a specialist skillset to promote health behaviours and improve health literacy.

Establishing youth-friendly health and care services can improve the health and wellbeing of children through early intervention and improving commissioning of services for young people.

Population covered

Careful consideration needs to be given to geographic coverage and boundaries. It is the responsibility of the commissioner to ensure that all children, young people, and their families who are resident or attending school in the local authority area should receive the healthy child programme.

There may be some local variation regarding boundaries, therefore reciprocal arrangements need to be in place to ensure children and young people receive the best support available, regardless of where they live.

The service provider will ensure that any coverage or boundary issues that may arise are escalated to commissioners for resolution, that they are then addressed in collaboration with neighbouring commissioners and providers ensuring children remain protected and safeguarded.

Delivery of a service that meets the needs, including safeguarding, of the child or young person must take precedence over any boundary discrepancies or disagreements.

Clarity needs to be provided regarding the provision for children who are home educated and how the service will support young people in further education settings.

Prioritisation

Response times and multi-agency working

The levels of service delivery and associated care pathways should be provided in full.

All referrals from whatever source, including children, young people and families transferring into area, should receive a response within 5 working days, with contact made with the child, young person or family within 10 working days.

Timings for mandated health reviews should be followed by, for example, a newborn visit, ideally within 10 to 14 days of the birth date.

Urgent referrals, including all safeguarding referrals, should receive a same day or next working day response to the referrer and contact within 2 working days and be in line with local safeguarding procedures.

Partnership with local maternity care providers should develop effective information sharing between maternity and health visiting services and integrated joined up services throughout pregnancy and the early weeks of life to improve outcomes and reduce inequalities.

Collaboration across organisational boundaries should develop care pathways that include delivery of key public health services.

As a child approaches school entry, transition to the local school nursing service should be initiated in accordance with local policy. Similarly, school nursing teams will work with adult services to ensure smooth transition to adult services.

Where public health nursing services are responsible for undertaking review health assessments and care plans on children in care, these must be completed to the national standards and within the statutory timeframe.

Where a child moves out of area, the public health nursing services should ensure that the child’s health records are transferred to the new area within 2 weeks of notification. Direct contact must be made to hand over all child protection cases and systems should be in place to assess the risk to children whose whereabouts are unknown.

Providers will comply with the national guidance for the management of safety concerns and incidents in screening programmes.

Safeguarding

Children and young people have the right to be protected from abuse and exploitation and to have their health and welfare safeguarded. Health visitors and school nurses work as part of a wider, multidisciplinary, multi-agency network and contribute to improving outcomes for children, young people and families.

All public health practitioners hold a critical role in the contextual safeguarding of children, families and communities, in accordance with the 2018 guidance Working together to safeguard children and the local partnership safeguarding plan. This is especially critical where children are supported by a protection plan or where there are identified safeguarding concerns.

In order that organisations, agencies and practitioners collaborate effectively, it is vital that everyone working with children and families, including those who work with parents or carers, understands the role they should play and the role of other practitioners. They should be aware of, and comply with, the published arrangements set out by the local safeguarding partners.

Health visitors and school nurses have an important role to play in safeguarding children and young people. Consideration may be given to locally agreed arrangements supported by a memorandum of understanding between public health commissioners and local safeguarding partners on the role provided by health visitors and school nurses at child protection and safeguarding meetings or to support vulnerable children.

The health visitor and school nurse draws on child and family-focused clinical and professional knowledge and expertise of what constitutes child maltreatment. They should be able to identify signs of sexual, physical or emotional abuse or neglect including domestic abuse, sexual exploitation, grooming and exploitation to support and or commit acts of terrorism (known as radicalisation), female genital mutilation, modern slavery, gang and electronic media abuse. If such signs are identified, the health visitor and school nurse should escalate accordingly - see the Royal College of Nursing intercollegiate document Safeguarding children and young people: roles and competencies for healthcare staff.

Local arrangements should take into account the role of health visitors and school nurses in ensuring the appropriate professional to provide health advice to safeguarding procedures, including child protection meetings, is the professional who knows the individual child and family best and who can therefore provide the best possible advice to inform decision-making.

In some instances, the health visitor or school nurse will be the health professional who has worked most closely with the child and who knows the child and family. Where this is the case, they would be the most appropriate health professional to attend child protection meetings. In other cases, it may be the GP, children and young people’s mental health practitioner or therapist who should be the lead practitioner. There should be consideration of the health visitor and school nurse liaison roles to contribute to and support multi-agency risk assessment conferences.

See appendix 2 for further details on key principles for working with children and young people aged 0 to 19, serious case reviews and identifying maltreatment.

Acceptance and inclusion criteria

The service must ensure equitable access for all children and young people aged 0 to 19 years and their families, regardless of disability, gender reassignment, marriage and civil partnership, sex or sexual orientation and race - this includes ethnic or national origins, colour or nationality, religion, belief or lack of belief.

Interdependencies: a whole system approach

Health visitor and school nursing services embed public health and prevention across health service pathways, promoting a whole system, holistic approach to prevention to make it easier for children, young people and families to receive the care and health promotion advice they need and to be referred quickly to effective prevention services.

A whole system approach to provide safer, personalised, accessible support and individualised care with vision and shared goals is central to improving outcomes for children, young people and families. Delivering such an approach is reliant on professionals and services working together, embracing IT, making efficient use of information to ensure and deliver high quality services.

Commissioners may also wish to consider securing provider representation on the health and wellbeing board or local partnership, including safeguarding. This can be supported through an area-based service structured in line with local children’s services, working together on integrated services for children and their families, with a focus on identification, early intervention, promotion and prevention.

A named health visitor or school nurse linked to each GP practice and appropriate setting (for example, a school) with an agreed schedule of regular contact meetings for referrals and collaborative service delivery can ensure direct partnership with schools to provide improved access and delivery of the healthy child programme and, through this, the health and wellbeing core offer.

Support for early years and education services in their delivery of health improvements should improve outcomes for children, young people and their families.

Promotion of the wide range of support that children and their families are entitled to should encourage children and young people to access the service. Promotion of an integrated approach should improve child and family health locally, leading to partnerships between early years settings, schools and other partner agencies including social care.

Health visitors and school nurses can link to wider stakeholders and services, for example, local emergency departments and the Supporting Families Programme team (or local equivalent).

Service user engagement to support the design, performance monitoring and evaluation of provision are important, as are local data sharing agreements for data about how well a child is across the local health economy, for example, details of immunisations and vaccinations.

Applicable service standards

Commissioners should pay due regard to the relevant National Institute for Health and Care Excellence (NICE) guidance and evidence base and ensure providers adhere to the guidance to support evidence-based delivery.

Supervision and registration of health visitors and school nurses

The commissioner needs to consider professional conduct of public health nursing as set out in the Nursing and Midwifery Council (NMC) code and ensure there is professional policy to provide both clinical and safeguarding supervision for all public health nursing staff (0 to 19). The safeguarding guidance and employer standards will be of particular interest to providers to support supervision.

Local authorities should be aware that all specialist community public health nurses need to meet the legal requirement for professional registration and revalidation. This must be in line with statutory requirements for practice issued by the NMC on revalidation.

Providers should ensure they have policies and procedures in place to provide clinical supervision, safeguarding supervision and mechanisms of risk assessment for any public health nursing service involved.

Further details on employer issues can be found in Supporting the public health nursing workforce: employer guidance.

Role of health visitors and school nurses in prescribing

Health visitors and school nurses have a key role to play in promoting and educating the public on the importance of self-care and signposting them to resources and local services. This includes, for example, helping children, young people and families to make daily choices to adopt a healthier lifestyle.

Health visitors and school nurses are in an ideal position to respond to common health concerns, improve parental health literacy and self-management of minor illnesses and injuries, discuss treatment options and wider management of conditions and then to prescribe as part of a holistic approach if indicated.

Nurse prescribing enhances the health visitor and school nurse ability to support families to manage minor illnesses, reducing hospital admissions - see Early years high impact area 5: improving health literacy, managing minor illnesses and reducing accidents. This can include managing symptoms and providing medication knowledge to enhance advice and support. It can also increase compliance to reduced hospital and GP attendances and reducing school absences.

Health visitors and school nurses who actively prescribe, should undertake regular prescribing updates and ensure ongoing competence to prescribe. More information can be found at The Nursing and Midwifery Council standards for prescribers.

Record keeping, data collection and information sharing

Providers need to ensure that robust systems are in place to meet the legal requirements of the Data Protection Act 2018 and safeguard personal data at all times.

Through this, and following good practice guidance, the provider will have agreed data sharing protocols with partner agencies, including other healthcare providers, children’s social care and the police to enable effective holistic services to be provided to children and their families. This will improve the co-ordination and communication between services and safeguard and protect children.

Electronic, contemporaneous clinical records should be kept, and accurate and appropriate data made available to all those with a duty of care for the child, including the child health information service (CHIS), to enable local, regional and national data reporting. This will support the delivery, review and performance management of services as well as support improvement in child health.

Data sharing agreements and arrangements for operational processes will need to be in place.

Local commissioners are encouraged to ensure that the delivery metrics and outcomes indicators for the 0 to 19 healthy child programme are covered in contracts or ‘in-house’ arrangements in a way that supports local data collection in the standard national format.

The contract with the service provider and the IT system supplier should specify that they have a responsibility to submit monthly data to the community services data set (CSDS) - formerly the children and young people’s data set (CYPHS).

Local authorities are encouraged to inform NHS England of health visiting and school nursing providers newly commissioned to deliver the healthy child programme, so coverage of the community services data set can be monitored, and uptake supported.

DCB3009 Healthy Child Record Standard provides instructions on standardising child health data in readiness to be shared via interoperability capabilities developed by NHS England. The purpose of this standard is to facilitate the sharing of standardised data between health care providers, parents and carers for all children. This will ensure that all appropriate stakeholders have access to consistent data structure and content to aid direct care decision-making. Providers through local contractual arrangements shall work with their system suppliers to implement the changes needed to facilitate this standard.

Materials, tools, equipment and other technical requirements

Public health contribution of nurses and midwives: guidance supports delivery.

All Our Health is a call to action for all healthcare professionals to use their skills and relationships to maximise their impact on avoidable illness, health protection and promotion of wellbeing and resilience.

Public health nursing teams (0 to 19) will also be required to access:

• validated tools for assessing development and identifying health needs
• personal child health records (often referred to as ‘the red book’) - paper or electronic according to local provision
• validated tools for assessing individual health outcomes, for example, Outcomes star
• IT systems and mobile technology for recording interventions and outcomes in the CHIS, thus capturing real time data and reducing duplication
• access to equipment to support agile working, for example, mobile phones and tablets
• equipment for measuring children’s weight and height
• use of social networking and other web-based tools to enable workforce training, professional networking and information and support for children, young people and families
• national and local campaign materials, for example, Start4Life, Change4Life, health promotion materials

Applicable quality requirements

The provider and the commissioner will work in collaboration to identify opportunities for leaner working and/or cost and efficiency savings at each quarterly review. This is likely to include consideration of how to make best use of modern technology and appropriate use of support staff within the health visitor and school nursing team and wider workforce. New technology should be considered to support service delivery and video conferencing may be considered to offer choice and personalisation when appropriate to need.

The provider should highlight where there is an absence of local services for onward referral to more specialist support so that future commissioning plans can include mitigation for provision of these. This is particularly urgent where need is identified but NICE guidance pathways are truncated at the onwards referral stage because local services do not currently exist.

Location of provider premises

The service should be available and accessible at times and locations that meet the needs of children, young people and families. Where possible, children, young people and families should be offered a choice of locations that best meets their needs, for example, children’s centres, schools, community centres, youth groups, general practice and, where appropriate, at home.

Specific details of location are to be agreed locally and should be based on engagement and feedback from key stakeholders, parents or carers, children and young people.

Reviews should be undertaken by the provider regularly to ensure they are suitable for local need and meet the quality indicators.

Providers should work with commissioners to consider how an appropriate level of service is provided throughout the year, including during school holidays. This can be achieved, for example, by providing online, text or telephone support. Services need to be responsive and flexible (for example, early mornings, lunchtimes, after school, evening and weekends) and should use technology and innovation to ensure that they reach children and young people.

Health and development reviews

The health visiting and school nursing contribution to the healthy child programme (0 to 19) includes the reviews and actions set out below.

Health promotion in prevention of unintentional injuries and accidents

This includes a range of activities to minimise risk.

Antenatal visit (mandated)

From 28 weeks of pregnancy, contact to be made by the health visiting service and an antenatal health promoting visit delivering comprehensive and holistic assessment of the expectant mother and father’s needs, including:

• assessing the mental health and wellbeing of both parents
• supporting the transition into parenthood
• promoting health by providing information and advice on:
  • the healthy child programme
  • local child health clinics
  • breastfeeding and nutrition
  • dental health
  • postnatal depression
  • domestic violence and abuse
  • female genital mutilation (FGM)
  • home and car safety
  • vitamins
  • smoking cessation
  • safer sleep
  • children’s centre services
  • local support networks
• Healthy Start vouchers

New baby review (mandated)

A new baby review in line with best practice guidance, ideally within 10 to 14 days of the birth date, includes:

• promotion of immunisations, specifically:
  • adherence to vaccination schedule for babies born to women who are hepatitis B positive
  • assess maternal rubella status and follow up of 2 MMR vaccinations (to protect future pregnancies)
• checking of the status of all screening results and taking prompt action to ensure appropriate referral and treatment pathways are followed in line with NHS population screening standards, specifically:
  • newborn blood spot screening - including all transfers in aged 1 and under, ensuring results for all conditions are present
  • results of newborn and infant physical examinations
• hearing screening outcome
• oral health advice
• breastfeeding, contraception, immunisations, safer sleep
• general health of newborn baby
• neonatal jaundice
• maternal mental health
• infant mental health

6 to 8 week review (mandated)

This includes:

• an assessment of progress from birth to 8 weeks, including:
  • check newborn blood spot (NBS) screening is completed
  • ensure first immunisations are given or booked
  • ensure that physical examination has taken place or give it
• promotion of immunisations, specifically:
  • promoting adherence to vaccination schedule for babies born to women who are hepatitis B positive
  • assessing maternal rubella vaccination history
  • checking of the status of all screening results and taking prompt action to ensure appropriate referral and treatment pathways are followed in line with NHS newborn blood spot (NBS) screening standards

The baby’s GP (or nominated primary care examiner) will have responsibility for ensuring the 6 to 8 week newborn infant physical examination screen is completed for all registered babies.

The review also includes promotion of:

• breastfeeding, including healthy eating and oral health
• advice for healthy diet and weight, including healthy sleep patterns
• immunisations
• managing minor ailments
• the prevention of accidents and socialisation
• infant and family mental health

3 to 4 month contact (not mandated - suggested)

This includes:

• infant feeding
• growth and development
• physical and social development
• home learning environment
• interaction
• oral hygiene
• maternal mental health

6 month contact (not mandated - suggested)

This includes:

• minor illness and accident prevention
• infant feeding
• growth and development
• home learning environment
• speech, language and communication development
• mental health
• returning to work

One year developmental review (mandated)

This is a review of health and development - best practice is to use a recognised tool for review such as ASQ3 and ASQ:SE2. The review includes provision of health promotion advice for:

• healthy diet and weight, including vitamin D
• oral health
• healthy sleep patterns
• immunisations
• managing minor ailments
• prevention of accidents
• socialisation

2 to 2 and a half year developmental review (mandated)

This is a holistic review of child health, development and growth, to identify children who are not developing as expected and/or in need of additional support. Use of a recognised tool for developmental review is mandatory for all children aged 2 across England.

The review includes:

• socialisation and behaviour management
• home learning environment
• speech, language and communication progress
• nursery provision
• diet
• hygiene
• oral health
• exercise and play
• general health and wellbeing

Emotional health and wellbeing of parent and child

An assessment of the mother (and father if present) should be made at the antenatal visit. Further assessments of the mother, father and baby should be made at:

• new baby review
• 6 to 8 week visit
• any contact between service and family
• one year developmental review
• 2 to 2 and a half year review (integrated where eligible)
• open access to service via telephone 9am to 5pm or healthy child clinics

Health development review

The review includes:

• school entry review to identify where targeted support may be needed for the child to reach their full health and wellbeing potential and contribute to social care assessment of needs, risks and choices for the child
• health visiting to school nursing transition to support school readiness, identifying the needs of children with additional or complex needs and referring to appropriate services
• health assessment Year 6 to Year 7 review, strengths and difficulties questionnaires (SDQs)
• mid-teen health review - local need to determine post-16 support including improving resilient and emotional wellbeing, delivering evidence-based interventions including oral health, HPV and other immunisation programmes

This review is offered within the teenage years, and at 16 to 19 to support young people as they move into adulthood and become more autonomous or require support in managing their health and care needs.

Healthy weight

The review includes:

• breastfeeding and complementary feeding advice as part of sugar reduction
• dietary advice (which should also consider dental health)
• evidence-based interventions, for example HENRY and the National Child Measurement Programme (NCMP), plus interventions on healthy weight and exercise

Targeted support

This includes:

• support for young carers’ health needs, looked-after children (and those on the edge of care), young offenders, children of military
• support for vulnerable parents, for example, young parents, those affected by mental health issues, drugs, alcohol and/or domestic violence
• early identification, support and training for complex or additional health needs, including dental health
• support for families, asylum seeking or refugee children, young people at risk of abuse or violence including domestic violence and abuse, child sexual abuse, child sexual exploitation and FGM, gangs and county lines

Sexual health and contraception

This includes contraceptive and pre-conception advice to parents, support to reduce teenage conceptions, improve preconceptual health and reduce sexually transmitted infections (STIs), including:

• puberty sessions
• condom distribution
• pregnancy testing
• enhanced service to prescribe long-acting reversible contraception
• emergency hormonal contraception
• STI testing
• postnatal contraception to prevent subsequent unplanned pregnancies

The review should also provide advice on preconceptual care before and between pregnancies to maximise maternal and fetal health, including immunisations, vitamin supplementation, smoking cessation and promotion of healthy weight.

Drugs, alcohol and tobacco

This includes prevention and support for drug and alcohol misuse and smoking cessation.

Emotional wellbeing

This includes supporting the emotional health and wellbeing early help offer, and specialist support.

Safeguarding

This includes supporting children, young people and families through integrated working.

Screening

This includes screening all children between 4 and 5 years of age for visual impairment in line with UK National Screening Committee guidelines.

Immunisation

This includes reviewing immunisation and vaccine status according to the complete routine immunisation schedule.

This is a review of health and development - best practice is to use a recognised tool for review such as ASQ3 and ASQ:SE2.

Locally defined strategies to achieve outcomes

The health visiting and school nursing services’ contribution to year-on-year improvements include the following outcomes, with suggested strategies and data sources.

Positive physical and emotional milestones

The aim is to get more children and young people to achieve positive physical and emotional milestones.

Suggested strategies and data sources include:

• mandated review and contacts
• screening for postnatal depression and anxiety
• completing a health visiting profile
• completing a school health profile, with data analysed and agreed priorities identified for each school or community setting, and services allocated to meet identified needs
• identifying the number of children, young people and families supported who are within:
  • universal reach
  • targeted response
  • specialist response

Improved academic results

The aim is to get more children and young people, particularly the most disadvantaged children, improved academic results to close the attainment gap between the most and least deprived.

Suggested strategies and data sources include recording:

• the number of interventions or contacts with children and young people who are considered vulnerable or from hard-to-reach groups
• ASQ-3 domain scores and EYFS scores recorded and interventions in place to reduce inequalities between lowest and highest IMD areas (Index of Multiple Deprivation)

Improved rates of school attendance

The aim is to get more children and young people to develop and achieve their potential, through improved rates of school attendance.

Suggested strategies and data sources include:

• the handover between health visiting and school nursing
• identification of speech, language and communication issues
• identification of dental issues and signposting to a dentist or dental team
• identification of continence issues and referral to appropriate services
• review of immunisation status
• puberty sessions in schools
• contribution to the development and co-ordination of individual healthcare plans for children with additional and complex health needs

Reducing numbers not in employment, education or training (NEET)

The aim is to enable more 16 to 19 year olds to achieve their potential by increasing the percentage of 16 to 19 year olds in employment, education or training, and reducing those not in employment, education or training (NEET).

Suggested strategies and data sources include:

• working with schools to identify persistent absentees due to health and wellbeing, including young carers
• delivery of support for health and wellbeing to improve attendance
• early identification of health needs of young carers and support provided tailored to individual need
• identification of health needs of asylum seekers and refugees, LGBTIQ or travellers
• identification of health needs of young offenders and signposting to appropriate services

Safe and protected, at home if possible

The aim is that all children and young people are safe and protected, within their families wherever possible.

Suggested strategies and data sources include:

• completion of statutory health assessments for looked after children and anonymised reporting of issues or concerns
• contribution to in care reviews, placement planning and support for foster or residential carers regarding health issues

Reduce hospital admissions and road traffic accidents

The aim is to:

• keep all children and young people safe and protected and thereby reduce hospital admissions caused by unintentional injuries to children and young people
• reduce the number of children and young people killed or seriously injured on the road

Suggested strategies and data sources include:

• brief Interventions with parents, children and young people
• awareness raising on injury prevention and promotion of child safety
• active follow-up of A&E attendances and anonymised reporting of issues to offer support and to determine trends
• identification of vulnerable families and refer into support services, for example, parenting programmes
• education programmes in schools and communities

Positive attachments with parents and carers

The aim is to get more children and young people to have a positive attachment with their parents and carers.

Suggested strategies and data sources include:

• promotion of positive parent-child interaction and parental attunement at all health visitor contacts
• early identification of children who are exhibiting signs of poor attachment and provision of or referral to targeted indicated interventions in accordance with local infant mental health pathways
• health visitors to assess maternal mental health at all health visiting mandated reviews

Healthy weight

The aim is to ensure more children and young people are at a healthy weight, through a reduction in the number children who are overweight and obese at 4 to 5 years and 10 to 11 years.

Suggested strategies and data sources include:

• promotion of breastfeeding
• evidence-based brief interventions
• promotion of healthy eating and reduction of sugar consumption for both healthy weight management and prevention of dental decay
• active referral and monitoring to family weight management service (where appropriate)
• promotion of healthy eating and physical activity in early years settings
• whole-school approach to healthy eating within targeted schools (see other guidance on the whole-school approaches)
• supporting and promotion of physical activity

More babies fed breast milk

The aim is to ensure more babies are fed breast milk.

The suggested strategy is to promote breastfeeding.

Better mental health

The aim is to ensure more pregnant women, parents, carers, children and young people have better mental health.

Suggested strategies and data sources include:

• care pathways clearly defined with other organisations and agencies providing level 1, 2 and/or 3 mental wellbeing services and other primary care providers, including perinatal mental health and infant mental health
• early identification and access for children and young people showing early signs of emotional distress or attachment difficulties for infants
• active referral and monitoring to child and adolescent mental health services
• whole-school approach to social and emotional wellbeing

Being smokefree

The aim is to ensure more pregnant women, parents, carers, children and young people are smoke free, reducing the prevalence of smoking locally.

Suggested strategies and data sources include:

• referrals to appropriate stop smoking services and advice regarding smoke free homes and cars
• nicotine replacement treatment prescribing
• whole-school approach to smoke-free policy within targeted schools

Reduce substance misuse

The aim is to ensure children and young people, parents and carers are supported to reduce substance misuse.

Suggested strategies and data sources include:

• use of age-specific screening and assessment tools to identify vulnerable young people and refer into services
• establish referral pathways with specialist young people’s substance misuse treatment
• services
• contribute to the delivery of drug and alcohol education within service and personal, social, health and economic education, tailored for primary, secondary and college ages as part of a whole-school approach to alcohol and drug harm reduction, including parents

Reduce teenage conception and improve sexual health

The aim is to ensure children and young people, and parents and carers, are supported to reduce teenage conceptions and improve sexual health.

Suggested strategies and data sources include:

• clearly defined care pathways with other organisations and agencies providing level 1, 2 and/or 3 sexual health services and other primary care providers
• brief interventions including all related risk-taking behaviour, for example, alcohol and unprotected sex
• active participation in development and delivery of personal, social, health and economic education
• active referral to sexual health services and monitoring
• active promotion and, where appropriate, prescribing of long-acting reversible contraceptives.
• access to emergency hormonal contraception and pregnancy testing
• referral to local chlamydia screening programmes

Increased immunisation

The aim is to have increased population immunisation coverage for children and young people, to reduce prevalence of preventable ill health.

Suggested strategies and data sources include:

• work with NHS teams and immunisation providers to achieve 90% coverage for vaccination programmes
• work with NHS England teams and immunisation providers to implement recovery plans in schools where this is not achieved
• promote immunisations with parents, young people and families

Be free of tooth decay

The aim is to ensure more children and young people grow up free of tooth decay.

Suggested strategies and data sources include:

• brief interventions, advice and guidance
• encourage attendance at a dentist and first dental check by one year
• signpost to any locally commissioned dental programmes
• inclusion of oral health within whole-school approach to healthy eating within early years and education settings
• identification of children where families need further support, for example, those where children already have tooth decay, those who have not had any dental care and those who have been admitted to hospital because of tooth decay

Appendix 1: support for children in mainstream education with additional health needs

Children with additional or complex health needs often require additional support to ensure a seamless transition into school, so they feel supported to learn within an education setting. Most children and young people with special educational needs or disabilities will have their needs met within local mainstream early years settings, schools or colleges.

Some children and young people may require a needs assessment in order for the local authority to decide whether it is necessary for it to make provision in accordance with an education, health and care (EHC) plan (see the SEND code of practice: 0 to 25 years).

Education, health and social care practitioners are required to co-operate at a local level to meet children and young people’s needs. Integrated care boards and local authorities will be required to commission services jointly for children and young people with special educational needs and disabilities.

Integrated care boards and local authorities (and the health and wellbeing board), as part of their continual processes of assessing and planning and their duty to prepare both the joint strategic needs assessment and joint health and wellbeing strategy, should work together to institute joint commissioning arrangements.

Although health visitors and school nurses have a vital role to play, effective support requires clear commissioning and collaboration between key partners. Schools and colleges have a contribution to make in supporting children and young people with additional or complex health needs. 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. Schools can co-commission with health and social care to ensure there is seamless support available.

There are 2 inspectorates, Ofsted and the Care Quality Commission (CQC) under the Area SEND: framework and handbook. Their inspectors review how local areas meet their responsibilities to children and young people (from birth to age 25) who have special educational needs or disabilities (or both). You can view all local area SEND reports and sign up to email alerts on the Ofsted reports site.

Appendix 2: safeguarding

Safeguarding is central to the role of health visitors and school nurses. The contribution both professionals make needs to be agreed locally to ensure their input is appropriate and timely. Effective partnership and multidisciplinary working underpin the core safeguarding principles which are outlined in this section.

Key principles for working with all children and young people aged 0 to 19 include:

• ensuring the safety and health of a child are intertwined aspects of their wellbeing - many health interventions also equip a child to stay safe
• working and communicating effectively within multi-agency teams to safeguard children and young people
• sharing information in line with good information governance. This is crucial to effectively safeguard children and young people - effective communication leads to effective partnership working
• ensuring that all children and young people have the right to protection from neglect, abuse and exploitation, and that their welfare is paramount
• recognising that it is in the child’s best interests to be brought up in their own family wherever possible. The child or young person must be seen in the context of a family
• ensuring parental rights and responsibilities are understood and considered, while ensuring the child’s best interests and safety. It should be recognised that the family may not always be the best place for the child
• ensuring children’s views and wishes are taken into account in line with the UN Convention on the Rights of the Child. Children and young people should be considered as individuals with particular needs and capacities for growth and development

• taking into account the 4 key recommendations of the CQC report Not seen, not heard, which are:

  • children and young people must have a voice
  • the focus must be on outcomes
  • more must be done to identify risk of harm to children
  • young people must have access to the emotional and mental health support they need

There are many factors that may contribute to child maltreatment. Child maltreatment: when to suspect maltreatment in under 18s (NICE guidelines CG89] provides a summary of clinical features associated with child maltreatment and alerting features that may be observed when a child presents to healthcare professionals. These include physical features such as bruising, bites, burns, fractures, head injuries, eye trauma, spinal injuries, organ damage, oral injuries, ano-genital signs and symptoms, and other non-specific injuries.

Factors that have been clearly established as placing children at an elevated risk for abuse, neglect and exploitation include parents or carers who:

• have a mental illness that is not adequately managed, including postpartum depression or psychosis
• are significantly misusing substances and/or alcohol
• experience or engage in intimate partner violence
• have a history of criminal or antisocial behaviours
• lack knowledge about child development or developmental milestones or have unrealistic expectations about their children’s developmentally appropriate behaviours
• have prior history of requiring child safeguarding or child protection services, or have had a child become looked after

Additionally, children are likely to be more vulnerable in families with parents or carers who:

• have severe intellectual disabilities
• a personal history of having been looked after
• are isolated from social support
• are from a background or culture that promotes harsh physical discipline

It is important to recognise that children and carers in the above circumstances can have healthy relationships and positive outcomes, but these issues can impact negatively on carer and child. Professionals will take into account the full family context and history when assessing risks and needs.

Learning the lessons from serious case reviews

A serious case review takes place after a child dies or is seriously injured and abuse or neglect is thought to be involved. It looks at lessons that can help prevent similar incidents from happening in the future. Working together to safeguard children and the Wood review of local safeguarding children boards sets out the need for professionals and organisations to protect children and young people, and to reflect on the quality of their services and to learn from their own practice and that of others.

Key lessons from serious case reviews include:

• information sharing is critical - in a significant percentage of case reviews, children remained in unsafe environments because information was not fully shared across agencies due to systemic obstacles, or because of a lack of awareness that each provider held a piece to a puzzle that would help social care providers to determine the child’s true level of risk

• poor engagement with services represents a risk factor - poor engagement may reflect cultural sensitivities, a carer’s ambivalence towards the child and the child’s needs, or poorly managed mental illness

• domestic abuse - health practitioners must be aware of the ongoing vulnerability of any child living in a context of domestic abuse, regardless of whether incidents of violence have been directed at the child

• a carer or other adult in the home with a criminal record for violent behaviour - health practitioners must be aware of the ongoing vulnerability of any child living in a family circumstance presenting such challenges for the child, also substance abuse, adult mental health problems and domestic violence

• parental beliefs and practices - professionals must show sensitivity and respect for parents’ beliefs and practices. However, this must not restrict an ongoing assessment of the impact of beliefs and practices on a child’s health and safety

• adults with learning difficulties which can impair their ability to parent appropriately will need assessment, support and services to ensure that they are able to adequately care for, and safeguard, their children

• housing issues including overcrowding and structurally dangerous conditions place children at increased risk and have contributed to fatalities. Local authorities need to be aware of children at increased risk due to poor housing conditions

• continuity of care is critical - health visitors and school nurses must stay engaged with local teams as long as it is necessary to ensure that a child’s safeguarding needs are fully addressed

Serious case reviews have also identified:

• infants (under one year old) are at the greatest risk of death from abuse and neglect, with infants under 3 months old at particular risk
• adolescents subject to abuse or neglect are at increased risk of death from suicide, and at sharply increased risk of child sexual exploitation

Memorandum of understanding (MoU)

Local areas need to agree a proactive approach to support the health visiting and school nursing safeguarding offer based on good practice and principles which DHSC are in process of developing.

Health visitors and school nurses deliver the healthy child programme and work as part of a wider, multidisciplinary, multi-agency network They work alongside other professionals including GPs, speech and language therapists and practice nurses to ensure that safeguarding needs of children and young people are met. This document considers how to support health visitors and school nurses towards:

• meeting public health outcomes
• creating opportunities for prevention and early intervention
• working in partnership to safeguard children

Children and young people have the right to be protected from abuse, harm and exploitation and to have their health and welfare safeguarded. All public health practitioners hold a critical role in the contextual safeguarding of children, families and communities, as per Working together to safeguard children guidance and the local partnership safeguarding plan. This is especially critical where children are on a protection plan or looked after.

Learning partnership aims and objectives

‘Working together to safeguard children’ guidance clarifies that ‘safeguarding’ is the action taken to promote the welfare of a child and to protect them from harm and is the ‘responsibility of everyone’.

Specific objectives are to:

• provide collaboration between organisations in delivering a change from traditional practices of safeguarding work in health visitors and school nurses to a more proactive approach
• support commissioners in commissioning more proactive roles for health visitors and school nurses to support the reduction in health inequalities in individuals, families and communities
• support service delivery partners and local safeguarding partnerships in adopting practices which enable a proactive approach. The final plans should be discussed with the local designated nurses for safeguarding

What does good look like?

This child centred approach, which includes Think Family, contextual safeguarding and trauma informed public health methodologies, is fundamental to safeguarding and promoting the welfare of every child. A child centred approach means keeping the child in focus when making decisions about their lives and working in partnership with them and their families.

Applying a whole systems approach to provide safer, personalised, accessible support and individualised care with vision and shared goals is central to improving outcomes for children, young people and families. Effective partnership and multidisciplinary working underpin the core safeguarding principles.

Role definition

In order that organisations, agencies and practitioners collaborate effectively, it is vital that everyone working with children and families, including those who work with parents or carers, understands the role they should play and the role of other practitioners. They should be aware of, and comply with, the published arrangements set out by the local safeguarding partners. The health visitor and school nurse draws on child and family-focused clinical and professional knowledge and expertise of what constitutes child maltreatment. They should be able to identify signs of sexual, physical or emotional abuse or neglect including domestic abuse, sexual exploitation, grooming and exploitation to support and or commit acts of terrorism (known as radicalisation), female genital mutilation, modern slavery, gang and electronic media abuse. If such signs are identified, the health visitor and school nurse should escalate accordingly.

Information sharing

Information sharing is essential for effective safeguarding and promoting the welfare of children and young people. It is a key factor identified in many serious case reviews where poor information sharing has resulted in missed opportunities to take action that keeps children and young people safe. All partners should commit to ongoing monitoring, with the aim of ensuring accountability and performance against agreed milestones.

NHS England ensures that the Child Protection Information Sharing (CP-IS) regularly sends secure listings of children with looked after status and those who have a child protection plan, to child health information services. This information then cascades to health visiting and school health teams.

The school nurse and health visiting service can use this integrated data to create improved case load management and create a meaningful dialogue with partner organisations at multi-agency safeguarding hubs, health and wellbeing boards, or any other partnership forum where population health outcomes are being discussed.

Since April 2020, all school nurse and health visiting services have had access to the NHS contextual safeguarding minimum data set which will profile their local authority for a range of contextual safeguarding and trauma informed practice indicators.

Appendix 3: measuring performance and outcomes

The following information on high impact areas is designed to assist local authorities in the commissioning of health visiting and school nursing services to lead and co-ordinate delivery of public health for children and young people aged 0 to 19.

Supporting the transition to parenthood and the early weeks

Under 18 conception rate

Definition: conceptions in women aged under 18 per 1,000 females aged 15 to 17.

Numerator: number of conceptions that occur within women aged under 18 that result in either one or more live births or stillbirths or a legal abortion under the Abortion Act 1967.

Denominator: number of women aged 15 to 17 living in the area.

Method of measurement: directly standardised rate per 100,000 population.

Collection and reporting responsibility and arrangements:

• routinely collected maternity and abortion figures
• ONS quarterly reporting at local authority level
• Public Health Outcomes Framework and in the Child and maternal health profiles

Smoking status at time of delivery

Definition: number of mothers known to be smokers at the time of delivery as a percentage of all maternities with known smoking status.

Numerator: number of women known to smoke at time of delivery.

Denominator: number of maternities where smoking status is known.

Method of measurement: percentage.

Collection and reporting responsibility and arrangements:

• collection by provider trusts’ maternity services
• quarterly reporting by NHS England at sub ICB level in Smoking status at time of delivery (SATOD) collection
• annual reporting in Public Health Outcomes Framework and in the Child and maternal health profiles including for local authorities

Low birth weight of term babies

Definition: live births with a recorded birth weight under 2,500g and a gestational age of at least 37 complete weeks as a percentage of all live births with recorded birth weight and a gestational age of at least 37 complete weeks.

Numerator: number of live births at term (greater than or equal to 37 gestation weeks) with low birth weight (less than 2,500g).

Denominator: number of live births at term (greater than or equal to 37 gestation weeks) with recorded birth weight.

Method of measurement: percentage.

Collection and reporting responsibility and arrangements:

• routinely collected birth registration data
• annual reporting in Public Health Outcomes Framework and in the Child and maternal health profiles including for local authorities

Infant mortality

Definition: infant deaths under 1 year of age per 1,000 live births.

Numerator: number of deaths of infants under one year, registered in the relevant period.

Denominator: number of live births occurring in the relevant period.

Method of measurement: rate per 1,000.

Collection and reporting responsibility and arrangements:

• via ONS
• via Public Health Outcomes Framework and in the Child and maternal health profiles

Supporting breastfeeding

Breastfeeding prevalence at 6 to 8 weeks after birth

Definition: percentage of infants being breastfed (fully or partially) at 6 to 8 weeks.

Numerator: number of infants at the 6 to 8 week check who are totally or partially breastfeeding.

Denominator: number of infants due a 6 to 8 week health review.

Method of measurement: percentage.

Collection and reporting responsibility and arrangements:

• collection via OHID’s interim reporting arrangements
• reported in the Public Health Outcomes Framework and in the Child andmaternal health profiles

Supporting healthy weight and physical activity

Reception: prevalence of overweight (including obesity)

Definition: proportion of children aged 4 to 5 classified as overweight or obese.

Numerator: number of children in reception (aged 4 to 5 years) classified as overweight or obese in the academic year. Children are classified as overweight (including obese) if their body mass index (BMI) is on or above the 85th centile of the British 1990 growth reference (UK90) according to age and sex.

Denominator: number of children in reception (aged 4 to 5 years) measured in the National Child Measurement Programme (NCMP) attending participating state maintained schools in England.

Method of measurement: percentage.

Collection and reporting responsibility and arrangements:

• collection is via local authority public health teams reporting to the NCMP
• annual reporting by the NCMP and in the Public Health Outcomes Framework and in the Child and maternal health profiles

Improving healthy literacy, reducing accidents and minor illnesses

A&E attendances (0 to 4 years)

Definition: A&E attendance rate per 1,000 population aged 0 to 4 years.

Numerator: A&E attendances for all children aged 0 to 4 years at the time of the attendance, with a valid gender in the data set, and resident in England. Children are assigned to the local authority of residence at the time of the A&E attendance. The counts are of all A&E attendances, including those where the patient was dead on arrival.

Denominator: mid-year population estimates for a single year of age and sex for local authorities in England and Wales; estimated resident population (ages 0 to 4 years).

Method of measurement: crude rate per 1,000 population.

Collection and reporting responsibility and arrangements:

• collection is via trusts’ routine reporting arrangements and requires no action by local authorities
• the Emergency Care Data Set (ECDS) is the data source
• annual reporting in the Child and maternal health profiles

Emergency admissions (0 to 4 years)

Definition: emergency admissions (rate per 1,000 population) aged 0 to 4.

Numerator: the number of finished emergency admissions (episode number = 1, admission method starts with 2) in children (aged 0 to 4 years). Admissions are only included if they have a valid local authority code.

Denominator: total population of the relevant age.

Method of measurement: crude rate per 1,000 population.

Collection and reporting responsibility and arrangements:

• collection is via trusts’ routine reporting arrangements and requires no action by local authorities (Hospital Episode Statistics are the source for this indicator)
• annual reporting in the Child and maternal health profiles

Hospital admissions - unintentional and deliberate injuries in children (aged 0 to 4 years)

Definition: crude rate of hospital admissions caused by unintentional and deliberate injuries in children aged under 5 years per 10,000 resident population aged under 5 years.

Numerator: the number of finished emergency admissions (episode number = 1, admission method starts with 2), with one or more codes for injuries and other adverse effects of external causes (ICD 10: S00-T79 and/or V01-Y36) in any diagnostic field position, in children (aged 0 to 4 years).

Denominator: mid-year population estimates for a single year of age and sex for local authorities in England and Wales; estimated resident population (ages 0 to 4 years).

Method of measurement: crude rate per 10,000 population.

Collection and reporting responsibility and arrangements:

• collection is via trusts’ routine reporting arrangements and requires no action by local authorities (Hospital Episode Statistics are the source for this indicator)
• annual reporting in the Public Health Outcomes Framework and in the Child and maternal health profiles

Supporting health, wellbeing and development (ready to learn, narrowing the ‘word gap’)

Percentage of 5 year olds with experience of visually obvious dental decay

Definition: percentage of 5 year olds with dental decay extending to the dentine layer which can be detected by visual observation alone.

Numerator: number of 5 year olds in a given area with at least one tooth decayed, missing or filled.

Denominator: number of 5 year olds examined for a given area.

Method of measurement: percentage.

Collection and reporting responsibility and arrangements:

• collected and reported through the Dental Public Health Epidemiology Programme for England oral health survey of 5 year old children (see the 2022 oral health survey) commissioned by local authorities as described in statutory instrument 3094 and as detailed in the single data list
• reported in the Public Health Outcomes Framework and Child and maternal health profiles

Hospital admissions for dental caries (0 to 5 years)

Definition: finished consultant episodes for dental caries among children aged 0 to 5, rate per 100,000.

Numerator: finished consultant episodes for all persons aged 0 to 5 years with primary operation F09 or F10 and primary diagnosis codes K021, K025, K028, K029, K040, K045, K046 or K047.

Denominator: mid-year population estimates for a single year of age and sex for local authorities in England and Wales; estimated resident population (ages 0 to 5 years).

Method of measurement: crude rate per 100,000 population aged 0 to 5 years.

Collection and reporting responsibility and arrangements:

• collection is via trusts’ routine reporting arrangements and requires no action by local authorities (Hospital Episode Statistics are the source for this indicator)
• reported in Child and maternal health profiles

Population vaccination coverage - MMR for 2 doses (5 years old)

Definition: all children for whom the local authority is responsible who received 2 doses of MMR on or after their first birthday and at any time up to their fifth birthday as a percentage of all children whose fifth birthday falls within the time period.

Numerator: total number of children whose fifth birthday falls within the time period who received 2 doses of MMR on or after their first birthday and at any time before their fifth birthday.

Denominator: total number of children whose fifth birthday falls within the time period.

Method of measurement: percentage.

Collection and reporting responsibility and arrangements:

• collected through the Cover of vaccination evaluated rapidly (COVER) programme
• reported in the Public Health Outcomes Framework and in the Child and maternal health profiles

Proportion of children aged 2 to 2 and a half years receiving ASQ-3 as part of the healthy child programme or integrated review

Definition: percentage of children who received a 2 to 2 and a half year review in the period for whom the Ages and Stages Questionnaire (ASQ-3) is completed as part of their 2 to 2 and a half year review.

Numerator: total number of children for which the ASQ-3 is completed as part of their 2 to 2 and a half year review.

Denominator: total number of children who received a 2 to 2 and a half year review by the end of the period.

Method of measurement: percentage.

Collection and reporting responsibility and arrangements:

• collection via OHID’s interim reporting arrangements
• reported and in the Child and maternal health profiles

Child development: percentage of children achieving expected level in communication skills at 2 to 2 and a half years

Definition: percentage of children who received a 2 to 2 and a half year review using ASQ-3 who were at or above the expected level in communication skills.

Numerator: all 2 to 2 and a half year reviews which have a score within the domain, where the scores are at or above the domain and questionnaire-specific threshold.

Denominator: all 2 to 2 and a half year reviews which have a score within the domain.

Method of measurement: percentage.

Collection and reporting responsibility and arrangements:

• collection via OHID’s interim reporting arrangements
• reported in the Public Health Outcomes Framework and in the Child and maternal health profiles

Child development: percentage of children achieving the expected level in gross motor skills at 2 to 2 and a half years

Definition: percentage of children who received a 2 to 2 and a half year review using ASQ-3 who were at or above the expected level in gross motor skills.

Numerator: all 2 to 2 and a half year reviews which have a score within the domain, where the scores are at or above the domain and questionnaire-specific threshold.

Denominator: all 2 to 2 and a half year reviews which have a score within the domain.

Method of measurement: percentage.

Collection and reporting responsibility and arrangements:

• collection via OHID’s interim reporting arrangements
• reported in the Child and maternal health profiles

Child development: percentage of children achieving the expected level in fine motor skills at 2 to 2 and a half years

Definition: percentage of children who received a 2 to 2 and a half year review using ASQ-3 who were at or above the expected level in fine motor skills.

Numerator: all 2 to 2 and a half year reviews which have a score within the domain, where the scores are at or above the domain and questionnaire-specific threshold.

Denominator: all 2 to 2 and a half year reviews which have a score within the domain.

Method of measurement: percentage.

Collection and reporting responsibility and arrangements:

• collection via OHID’s interim reporting arrangements
• reported in the Child and maternal health profiles

Child development: percentage of children achieving the expected level in problem solving skills at 2 to 2 and a half years

Definition: percentage of children who received a 2 to 2 and a half year review using ASQ-3 who were at or above the expected level in problem solving skills.

Numerator: all 2 to 2 and a half year reviews which have a score within the domain, where the scores are at or above the domain and questionnaire-specific threshold.

Denominator: all 2 to 2 and a half year reviews which have a score within the domain.

Method of measurement: percentage.

Collection and reporting responsibility and arrangements:

• collection via OHID’s interim reporting arrangements
• reported in the Child and maternal health profiles

Child development: percentage of children achieving the expected level in personal-social skills at 2 to 2 and a half years

Definition: percentage of children who received a 2 to 2 and a half year review using ASQ-3 who were at or above the expected level in personal- social skills

Numerator: all 2 to 2 and a half year reviews which have a score within the domain, where the scores are at or above the domain and questionnaire-specific threshold.

Denominator: all 2 to 2 and a half year reviews which have a score within the domain.

Method of measurement: percentage

Collection and reporting responsibility and arrangements:

• collection via OHID’s interim reporting arrangements
• reported in the Public Health Outcomes Framework and in the Child and maternal health profiles

Child development: percentage of children achieving a good level of development at 2 to 2 and a half years

Definition: percentage of children who received a 2 to 2 and a half year review who were at or above the expected level of development in all 5 ASQ 3 domains

Numerator: all 2 to 2 and a half year reviews which have a score within all 5 domains, where the scores are at or above the domain and questionnaire-specific threshold.

Denominator: all 2 to 2 and a half year reviews which have a score within all 5 domains.

Method of measurement: percentage.

Collection and reporting responsibility and arrangements:

• collection via OHID’s interim reporting arrangements
• reported in the Public Health Outcomes Framework and in the Child and maternal health profiles

School readiness: percentage of children achieving a good level of development at the end of reception

Definition: children defined as having reached a good level of development at the end of the early years foundation stage (EYFS) as a percentage of all eligible children.

Numerator: all children defined as having reached a good level of development at the end of the EYFS by local authority. Children are defined as having reached a good level of development if they achieve at least the expected level in the early learning goals in the prime areas of learning (personal, social and emotional development; communication and language) and the early learning goals in the specific areas of mathematics and literacy.

Denominator: all children eligible for the EYFS profile by local authority.

Method of measurement: percentage.

Collection and reporting responsibility and arrangements:

• published by the Department for Education
• available in Public Health Outcomes Framework and in the Child and maternal health profiles.

Supporting resilience and wellbeing

Hospital admissions as a result of self-harm (10 to 24 years)

Definition: directly standardised rate of finished admission episodes for self-harm per 100,000 population aged 10 to 24 years.

Numerator: number of finished admission episodes in children and young people aged between 10 and 24 years where the main recorded cause is between X60 and X84 (intentional self-harm).

Denominator: mid-year population estimates for a single year of age and sex for local authorities in England and Wales (ages 10 to 24 years).

Method of measurement: directly standardised rate per 100,000 population.

Collection and reporting responsibility and arrangements: Child and maternal health profiles.

Hospital admissions as a result of self-harm (10 to 14 years)

Definition: crude rate of finished admission episodes for self-harm per 100,000 population.

Numerator: number of finished admission episodes in children aged between 10 and 14 years where the main recorded cause is between X60 and X84 (intentional self-harm).

Denominator: mid-year population estimates for a single year of age and sex for local authorities in England and Wales (ages 10 to 14 years).

Method of measurement: crude rate per 100,000 population.

Collection and reporting responsibility and arrangement: Child and maternal health profiles.

Hospital admissions as a result of self-harm (15 to 19 years)

Definition: crude rate of finished admission episodes for self-harm per 100,000 population.

Numerator: number of finished admission episodes in children aged between 10 and 14 years where the main recorded cause is between X60 and X84 (intentional self-harm).

Denominator: mid-year population estimates for a single year of age and sex for local authorities in England and Wales (ages 15 to 19 years).

Method of measurement: crude rate per 100,000 population.

Collection and reporting responsibility and arrangements: Child and maternal health profiles.

Improving health behaviours and reducing risk taking

Children killed and seriously injured (KSI) on England’s roads

Definition: crude rate of children aged 0 to 15 years who were killed or seriously injured in road traffic accidents per 100,000 population.

Numerator: number of children aged 0 to 15 years that were killed or seriously injured in road traffic collisions.

Denominator: ONS mid-year population estimates for a single year of age and sex for local authorities and integrated care boards in England and Wales (ages 0 to 15 years).

Method of measurement: crude rate per 100,000 population.

Collection and reporting responsibility and arrangements: Child and maternal health profiles.

Hospital admissions caused by unintentional and deliberate injuries in children (aged 0 to 14 years)

Definition: crude rate of hospital admissions caused by unintentional and deliberate injuries in children aged under 15 years per 10,000 resident population aged under 15 years.

Numerator: the number of finished emergency admissions, with one or more codes for injuries and other adverse effects of external causes (ICD 10: S00 to T79 and/or V01 to Y36) in any diagnostic field position, in children (aged 0 to 14 years).

Denominator: mid-year population estimates for a single year of age and sex for local authorities in England and Wales; estimated resident population (ages 0 to 14 years).

Method of measurement: crude rate.

Collection and reporting responsibility and arrangements: Public Health Outcomes Framework.

Supporting healthy lifestyle

Smoking prevalence age 15 years, regular smokers

Definition: smoking prevalence among 15 year olds - regular smokers.

Numerator: number of 15 year olds classified as regular smokers (at least one cigarette per week).

Denominator: number of 15 year olds surveyed in the ‘Smoking, drinking and drug use among young people in England’ survey.

Method of measurement: percentage (weighted).

Collection and reporting responsibility and arrangements:

• NHS England: Smoking, drinking and drug use among young people in England
• Public Health Outcomes Framework

Year 6: prevalence of overweight (including obesity)

Definition: proportion of children aged 10 to 11 classified as overweight or obese. Children are classified as overweight (including obese) if their BMI is on or above the 85th centile of the British 1990 growth reference (UK90) according to age and sex.

Numerator: number of children in year 6 (aged 10 to 11 years) with a valid height and weight measured by the NCMP with a BMI classified as overweight or obese.

Denominator: number of children in year 6 (aged 10 to 11 years) measured in the NCMP mainly attending participating mainstream state-maintained schools in England.

Method of measurement: percentage.

Collection and reporting responsibility and arrangements:

• NCMP
• NHS England
• Public Health Outcomes Framework

Chlamydia detection rate aged 15 to 24 years

Definition: all chlamydia diagnoses in 15 to 24 year olds attending sexual health services (SHSs) and community-based settings, who are residents in England, expressed as a rate per 100,000 population. Data excludes people accessing services located in England who are residents in Wales, Scotland, Northern Ireland or abroad. The England total includes tests which did not have sufficient location information to be attributed to a local authority of residence.

Numerator: number of diagnoses of chlamydia among 15 to 24 year olds.

Denominator: ONS mid- year resident population estimate for age 15 to 24 years.

Method of measurement; crude rate per 100,000 population aged 15 to 24 years.

Collection and reporting responsibility and arrangements: Public Health Outcomes Framework.

Supporting vulnerable young people and improving health inequalities

Pupil absence

Definition: percentage of half days missed by pupils due to overall absence (including authorised and unauthorised absence).

Numerator: number of sessions missed due to overall absence.

Denominator: total number of possible sessions.

Method of measurement: percentage.

Collection and reporting responsibility and arrangements: Public Health Outcomes Framework.

Teenage mothers

Definition: percentage of delivery episodes where the mother is aged under 18 years.

Numerator: total number of maternal episodes, mother aged between 12 and 17 years.

Denominator: total number of maternal episodes.

Method of measurement: percentage.

Collection and reporting responsibility and arrangements: Child and maternal health profiles.

Admission episodes for alcohol-specific conditions - under 18s

Definition: admissions to hospital for under 18s where the primary diagnosis or any of the secondary diagnoses are an alcohol- specific (wholly attributable) condition. Crude rate per 100,000 population.

Numerator: the number of hospital admission episodes for under 18s where the primary diagnosis or any of the secondary diagnoses are an alcohol-specific (wholly attributable) condition code only.

Denominator: ONS mid-year population estimates for 0 to 17 year olds. Three years are pooled.

Method of measurement: crude rate per 100,000 population.

Collection and reporting responsibility and arrangements: Child and maternal health profiles.

Hospital admissions due to substance misuse (15 to 24 years)

Definition: directly standardised rate of hospital admission for substance misuse, per 100,000 population aged 15 to 24 years.

Numerator: number of hospital admissions where the primary diagnosis is one of substance misuse.

Denominator: ONS mid-year population estimates aged 15 to 24 years.

Method of measurement: directly standardised rate per 100,000 population.

Collection and reporting responsibility and arrangements: Child and maternal health profiles.

Unplanned admission for asthmas, diabetes or epilepsy in under 19 years

Definition: rate for unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s.

Numerator: the number of finished and unfinished continuous inpatient spells, excluding transfers for patients aged under 19 with an emergency method of admission and where asthma, diabetes or epilepsy was the primary diagnosis.

Denominator: registered patients aged under 19.

Method of measurement: directly age and sex standardised admission rate per 100,000 registered patients.

Collection and reporting responsibility and arrangements:

• Public health Outcomes Framework
• Child and maternal health profiles

First time entrants to the youth justice system

Definition: rate of 10 to 17 year olds receiving their first reprimand, warning or conviction per 100,000 population.

Numerator: number of juveniles (10 to 17 year olds) receiving their first conviction, caution or youth caution.

Denominator: mid-year populations (10 to 17 year olds).

Method of measurement: crude rate.

Collection and reporting responsibility and arrangements: Public Health Outcomes Framework.

Supporting self-care and improving health literacy

Average Attainment 8 score

Definition: average Attainment 8 score for all pupils in state-funded schools, based on local authority of pupil residence.

Numerator: total Attainment 8 scores of pupils at the end of key stage 4 in all maintained secondary schools, academies and free schools, by local authority of pupil residence.

Denominator: number of pupils at the end of key stage 4 in all maintained secondary schools, academies and free schools, by local authority of pupil residence.

Method of measurement: average score.

Collection and reporting responsibility and arrangements: Child and maternal health profiles.

Associated tools and guidance

Children and young people’s mental health: government response, DHSC, 2022

Health equity in England: the Marmot Review 10 years on, The Health Foundation, 2020

NHS 5 year forward view, NHS England

Teenage pregnancy prevention framework, Public Health England, 2018