Healthy Child Wales Programme: for school aged children - Part 1: introduction

The Healthy Child Wales Programme for children aged 0 to 7 years old was launched in 2016.

Part 2 of Healthy Child Wales, the operating model, sets out the planned contacts children, young people and their families can expect from their health boards, commencing at school entry (5 years old) through to the final year of compulsory schooling in Wales (16 years old).

These universal contacts cover 3 areas of intervention:

• screening
• immunisation
• monitoring and supporting child health and development

The new national operating model is needed to underpin the existing school nursing frameworks (part 1 2017 and part 2 2018) to clearly define the school nursing services provided by NHS Wales.

This guidance consists of 8 parts as set out below:

• Part 1: introduction
• Part 2: school entry health review
• Part 3: population health needs assessment
• Part 4: public health interventions
• Part 5: supporting children through school ages and stages
• Part 6: summary of the immunisation schedule
• Part 7: safeguarding
• Part 8: relationships and sexuality education

The Welsh Government expects that every child and young person of compulsory school age will be offered the Healthy Child Wales Programme. 

School nursing services will provide equitable health provision for school age children across Wales by:

• introducing a standardised operating model for school nursing services for all compulsory school aged children across Wales, regardless of setting
• producing a clear set of pathways for children and young people to access support tailored according to their level of need
• improving the health and wellbeing of school aged children and support them to make informed choices as they develop through childhood and adolescence by delivering evidence based public health programmes and prioritising high impact areas of need, including:
  • health and growth
  • supporting the prevention of communicable infectious diseases
  • whole school approach, including emotional health and wellbeing
  • relationships and sexuality
  • transition
  • nutrition, hydration and weight management
  • smoking cessation
  • healthy lifestyle and choices
  • alcohol and substance misuse
• supporting children and young people to make informed choices throughout school life to reduce health inequalities and improve public health outcomes
• raising awareness of the school nursing services role, including healthcare professionals engaged in delivering the Healthy Child Wales Programme, with children and young people, parents/carers, families and other public service organisations
• making sure safeguarding is embedded throughout the new unified operating model

Public and independent schools are outside the scope of the new unified operating model, as are sixth form colleges.

The operating model for school aged children in Wales, forming part of the Healthy Child Wales Programme, will be delivered by school nursing services within NHS Wales. School nursing services in Wales are professionally led by senior nurses with a post graduate specialist community public health nurse qualification in school nursing.

There are a range of nursing roles delivering school nursing services in Wales, regardless of setting. The qualifications, skill set and expertise of the nurses defines which children and young people they work with. For example, nurses with a specialist post graduate qualification in community public health (school nursing) deliver services for mainstream schools and children and young people educated other at school.

Whilst in contrast, a range of children’s nurses work in special schools and there is not a single defined special school nurse role in Wales. Due to the size and scale of the work required, workforce has been identified as a key implementation workstream of the operating model, with the clear aim of working towards greater consistency across Wales over the duration of the implementation period.

Within the new operating model the nursing roles which typically make up school nursing services in Wales are described as follows.

Specialist community public health nurse (school nursing)

Specialist community public health nurses (school nursing) are professionals at the frontline of public health. They are independent practitioners who are committed to improving children and young people’s health and wellbeing. Due to their post graduate learning and experience, they have expertise in relation to understanding the wider determinants of health and tackling health inequalities across the diverse communities they support. They are uniquely linked to a specific secondary school and the cluster primary schools. They work in partnership with schools, communities and families across three levels of support, according to:

• need to prevent ill health
• protect health
• promote wellbeing

Registered nurse (school nursing)

The registered nurse (school nursing) has delegated responsibility to support the universal and enhanced offer to prevent ill health, protect health and promote wellbeing. The nurse works both alone and as part of a team with confidence to make decisions without supervision. The role includes identifying the health needs of school-aged children, through an ongoing programme of:

• health surveillance
• assessment
• monitoring
• referral
• interventions
• working effectively with children, their families and parents/carers

Unregistered workforce (school nursing)

The unregistered workforce (school nursing), works in a variety of community settings to provide both clerical and clinical support to deliver services, involving direct contact with school-aged children under the direction of the specialist community public health nurse (school nursing) and other members of the service.

Community children’s nurses and nurses in special schools

In addition to the nursing roles described above, which predominantly cover the universal elements of the operating model, there are also a range of key nursing roles which support children and young people with complex healthcare needs. The roles are unique in the level of co-ordination and connectivity provided between the team around the child and wider professionals and services. These nurses support the school to safely manage the child’s health and wellbeing needs, so that learning opportunities are optimised, and the child or young person is included in school activities.

Through the delivery of the new operating model, school nursing services are committed to fulfilling their duties as part of the wider NHS Wales obligation to follow key legislation and drivers in Wales.

A healthier Wales is the long-term plan for health and social care in Wales.

The Well-being of Future Generations (Wales) Act (2015) came into force in April 2016 and seeks to improve the social, economic, environmental and cultural wellbeing of Wales. NHS Wales along with other public bodies are required to:

• think more about the long-term
• work better with people, communities and each other
• look to prevent problems
• take a more joined-up approach

Children and young people are central to the legislation and school nursing services will ensure the ways of working are embedded in the delivery of the new operating model.

The Social Services and Well-being (Wales) Act (2014) provides the legal framework for transforming social services in Wales. The Act has integration at its heart and has implications for the Welsh NHS and the way in which services are delivered by school nursing services.

The United Nations Convention on the Rights of the Child (UNCRC) is the basis for all Welsh Government work with children and young people, with the 7 core aims for developing policy for children and young people. The Rights of Children and Young Persons (Wales) Measure 2011, imposes a duty on Welsh Ministers to have regard to children’s rights set out in the UNCRC. The Children’s Rights Scheme 2014 sets out the arrangements for Welsh Ministers to comply with the duty to have due regard to children’s rights when exercising any functions.

The standards have been ratified by the Welsh Government and are underpinned by the UNCRC and the Well-being of Future Generations (Wales) Act (2015), that puts the involvement of children at the heart of improving their wellbeing. The standards have been adapted to make them more accessible for disabled children and young people under the name of "having a voice, having a choice".

The Duty of Quality is a legal responsibility that requires Welsh Ministers and the NHS to think about how their decisions will improve health care in the future. It also requires them to talk to the public openly and with transparency about the quality of health care. School nursing services are committed to following the Duty of Quality and will ensure it is considered in all their processes and systems, and when making decisions regarding services for children and young people.

The Additional Learning Needs and Educational Tribunal (Wales) Act (2018) makes provision for a new statutory framework for supporting children and young people with additional learning needs. A unified legislative framework to support all children of compulsory school age or below with additional learning needs.

In line with the Nurse Staffing Levels (Wales) Act (2016), health boards have a legal duty to regard the importance of ensuring appropriate levels of nurse staffing in all settings.

Additionally, the Strategic Equality Plan 2020 to 2024, the Anti-racist Wales Action Plan, More than just words 2022 to 2027 and the LGBTQ+ Action Plan will be used by school nursing services when delivering the operating model to embed meaningful changes and values as part of Welsh life. The Anti-racist Wales Action Plan must be used to deliver demonstrable school nursing leadership at all levels, to meet existing commitments to challenge systemic and institutional racism and in the provision of equitable, culturally appropriate services, recognising intersectionality and differences among groups.

More than just words 2022 to 2027 will strengthen Welsh language provision in health and social care, and school nursing services will support Welsh speakers to receive care in their first language.

The LGBTQ+ Action Plan, developed with the aim of making Wales the most LGBTQ+ friendly nation in Europe, sets out healthcare, social care and welfare actions NHS Wales must deliver against, and school nursing services will deliver their part accordingly.

The focus of Healthy Child Wales is upon the universal contacts which are delivered by school nursing services. The universal proportionalism approach ensures the intensity of healthcare is increased as the levels of healthcare needs increase. In line with this approach, the delivery of school nursing services intensifies across 3 levels of need.

In summary, the 3 levels originally introduced in the Healthy Child Wales Programme were:

• universal: the core minimum intervention offered to all children and young people, regardless of need
• enhanced: additional interventions based on the assessment and analysis of resilience and identification of additional need
• intensive: further interventions built upon ongoing assessment and analysis of greater need

School nursing services will plan the delivery of support offered to children, young people and families using a universal, enhanced, and intensive structured approach. This approach helps services tailor the support to different needs within the population, ensuring the children, young people and families receive the most appropriate level of care based on healthcare needs. The levels of support for school aged children and young people are detailed further under each of the relevant sections of the operating model.

In the longer term and through the implementation stage of the new operating model, NHS Wales, led by the All Wales Heads of School Nursing Advisory Forum, will review the implications of the five levels of care for school nursing services in Wales.

The new unified operating model will be offered to all school aged children regardless of setting. In practice this means that the health and development offer in special and mainstream schools will also be offered to children and families who opt to educate at home, or who are educated in a location other than at school. It will be delivered through a variety of methods including digital channels and signposting children and young people to the right service to meet their needs and circumstances. This will require partnership working with other parts of NHS Wales and local authority partners, underlining the importance of a team around the family approach to public health and development.

As part of the commitment to providing services to support children and young people throughout the school age, an important aspect of the role of school nursing services is provision in the community and multi-agency working with local authorities and other public service partners and the third sector. The aim of this community outreach is to meet children and young people in the communities in which they live and raise the profile of school nursing services. Examples include multi-agency community engagement events and community drop-in sessions.

To support the implementation of the new operating model, NHS Wales and Welsh Government have agreed a 2 year implementation period commencing in April 2024. This will give each health board time to take account of the requirements and different approaches currently across Wales and then implement fully. At the end of the 2 year period in April 2026, Welsh Government and NHS Wales will conduct an implementation review.

School nursing services will prioritise the following implementation workstreams.

Workforce and training

This includes looking at the nurse staffing level implications longer term and the 5 levels of care approach, as well as exploring opportunities for:

• consistent job descriptions
• workforce re-design to meet changing case-mix needs
• skill mix within teams
• learning and development needs

Monitoring framework

The development of a proportionate monitoring framework to measure the impact and quality of the new operating model. This will include support from experts in knowledge and analysis to define clear outputs and outcomes for school nursing services in Wales.

Digital and data

Across Wales there is still an over reliance on paper records. As a result, there is an urgent need to establish a digital and data workstream led by heads of school nursing services. This will drive forward transformation and will influence the wider digital and data agenda in NHS Wales to ensure digital services for children and young people, including school nursing are prioritised. Patient safety and quality improvement is central to this workstream to make sure that school nursing services are able monitor and measure the impact of their services and the outcomes for children and young people in Wales.

Communication and engagement

This workstream will be focused on maximising opportunities for promoting a vibrant and modern school nursing service for Wales. The first task for this workstream will be to produce an innovative communications and engagement plan, aimed at using digital channels to raise the profile of school nursing services.

At the heart of the operating model are a series of core contacts which school nursing services will offer to school aged children in Wales between the ages of 5 and 16. This is traditionally the start and end of compulsory education for most children and young people.

• School entry health review: age 5 (reception stage).
• Population health needs assessments: by the end of the first academic term and annually reviewed thereafter.
• Public health intervention: each school nursing cluster will select up to 3 high impact areas covering the primary school age (5 to 11 years old), reflecting the local health needs of the population.
• Relationships and sexuality education: ages 10 to 11 (years 5 and 6).
• Transition into secondary school: ages 10 to 11 (year 6).
• Flu education and offer of vaccination: school based annually from reception (year 6).
• Single point of access for parents/carers and families: ages 5 to 11 (reception to year 6).
• Safeguarding: ages 4 to 11 years old (reception to year 6). Represents an intensive level of support where identified by school nursing services.
• Population health needs assessments: 12 to 16 years old (years 7 to 11).
• Healthy relationships: 11 to 12 years old (year 7).
• Public health intervention: 2 high impact areas and the healthy relationships session, 12 to 15 years old (years 8 and 10).
• Relationships and sexuality education: 13 to 14 years old (year 9).
• Human papillomavirus (HPV) education and offer of single dose vaccination: 12 to 13 years old (year 8).
• Teenage booster (Td/IPV-MEN-ACWY vaccine) education and offer of vaccination: 13 to 14 years old (year 9 pupils in school).
• Transition to further education, employment: a universal offer for young people aged 15 to 16 (year 11).
• Flu education and offer of vaccination: offered annually for ages 11 to 16 (years 7 to 11).
• MMR catch ups: targeted at children / young people aged 11 to 16 (years 7 to 11). Approach varies across health boards currently. Delivered jointly with NHS Wales Executive.
• Single point of contact: drop-in for children / young people aged 11 to 16 years old (years 7 to 11).
• Single point of access for parents/carers and families: offered for children / young people aged 11 to 16 years old (years 7 to 11).
• Safeguarding: for children / young people aged 11 to 16 years old (years 7 to 11). Represents an intensive level of support where identified by school nursing services.

The new operating model will be monitored for impact, without creating significant burden upon existing services. In the short-term, a series of high-level outputs have been defined by the project to aid successful implementation and monitoring. In the medium-term, a workstream led by senior school nursing leads in Wales will develop a robust outcomes framework, with the support of expertise in children’s health outcomes measurement.

The output measures will include:

• percentage completion rate of School Entry Health Reviews (SEHRs) for children with enhanced or intensive levels of care need (number of SEHRs completed as a percentage of the total enhanced and intensive level of care reception age population)
• percentage of first population health needs assessments completed by end of the first academic year (end December)
• percentage completion of population health needs assessments annual reviews
• 100% of children / young people with an enhanced or intensive level of care with an assigned a care co-ordinator
• number of healthy relationships sessions delivered each year
• reported compliance with each national standard for immunisations
• vaccination and immunisation outputs reported by the Public Health Wales Observatory
• percentage of initial health needs assessments completed prior to initial case conference for safeguarding (target 100%)
• number of children and young people educated other school (including elected home educated) reached by school nursing services
• number of children and young people participating in drop-in sessions
• percentage of completion of child measurement programme activity against the reception age population
• number of children supported and followed up by school nursing services due to weight and height criteria
• percentage increase in awareness of school nursing services (parental surveys by school nursing services)

Team around the child is a phrase which is used to describe a preventative approach undertaken by public service professionals, often in a multi-agency context, to support a child or young person with their needs. 

In the context of the operating model, this refers to their health and wellbeing needs. A team around the child is a virtual multi-agency team made up of the child / young person, family and professionals who know the child best. For children and young people with complex health needs who require an enhanced or intensive tier of support, they will form a core team, working together, to meet the child’s individualised needs. There is longstanding evidence which supports the effectiveness of this approach for children and young people, especially for those with complex health needs.

Within this operating model, we are focussing specifically on a school-based team around the child approach. When the school nursing services representative undertakes a care co-ordinating role (already set out in part 2 school nursing framework: nursing in special schools), they will engage a mix of professionals drawn from the following areas, as required:

• allied health professionals and therapists, such as physiotherapists or occupational therapists
• paediatricians
• general practitioners and primary care practitioners, such as practice nurses
• learning disability or emotional mental health team and/or nurses
• teacher/school representatives
• early help practitioners
• secondary care and tertiary care practitioners, such as hospital doctors or specialist nurses
• other multi-agency representatives as appropriate

In 2017, Public Health Wales launched Every Child Wales, with a vision of creating the "go to" brand for health information in the early years (typically 0 to 7 years of age) for families in Wales. The new Every Child Wales parent information offer has been broken down into 4 standalone resources covering:

• your pregnancy and birth (published spring 2023)
• newborn to age 2 (due January 2024)
• age 2 to starting school
• age 4 to 7

Additionally, school nursing services provide a range of information through digital channels for children, young people and their parents/carers at key stages of their journey through the school age. This information includes:

• a welcome pack at the age of 4 to 5 years old
• information in relation to growing up and puberty
• information for young people preparing to leave compulsory education for work, training or further education
• key public health information throughout the school age in relation to the relevant high impact public health issues for the school or wider area, or in response to a public health need

School nursing services also signpost children and young people to age-appropriate information to support them to make healthy and safer lifestyles choices as they grow up and leave compulsory education.