Developing a school nursing activity demand model for Staffordshire.
The purpose of this paper is to present the rationale, development and application of a new activity demand model for school nursing. The model created in Staffordshire in 2012 was a collaborative venture between the public health department and local school nurse professionals. It was designed, developed and implemented by the authors in the absence of a more suitable alternative to underpin and inform the redesign of school nurse teams covering the boundaries of Staffordshire County Council.
The model uses a health needs assessment approach and brings together key components for consideration: population health data; activity of school nurse workforce; population numbers of school-aged children; and a breakdown of components of the Healthy Child Programme (HCP) and public health outcomes for children and young people.
The context for the creation of the model is important and included the transfer of the public health commissioning responsibilities from the NHS to local government; the launch of the Department of Health's (DH) revitalised vision and strategy for school nursing (DH, 2012a); and local organisational requirements to review and redesign the local school nurse workforce.
Central to the review process was a collaborative commissioning approach, with public health acting as the bridge between commissioning colleagues in Staffordshire County Council and the local NHS provider service (Staffordshire and Stoke-on-Trent Partnership Trust), which manages and delivers school nursing services.
The collective vision on which to base the review was agreed as follows:
'To develop a high-quality, needs-led service; locally owned; driven by professionals and well respected by young people, partners and NHS colleagues, that delivers on agreed and shared outcomes'.
The model was based on a health needs assessment approach (Commissioning Support Programme, 2009) and best practice was developed as a starting point for the review process. There are very few published models across the country that prescribe what the school nursing workforce should look like to deliver the HCP.
School nurses are responsible for delivery of the HCP for five to 19 years (DH, 2009a). This compliments the health visiting programme (DH, 2009b), which is also subject to a transformation programme by 2015/16 (DH, 2011).
School nurses are highly trained in public health skills, and are accessible to young people and their parents within a given community. They act as conduits between NHS services, schools and the community, offering a unique role that encompasses public health leadership, the delivery and planning of health interventions on a one-to-one and population-wide basis for school-aged children. This includes health promotion, advice, treatment of some conditions, education, service co-ordination and management. School nurses often carry an active caseload and play a key role in safeguarding.
The demographic profile of Staffordshire was a major consideration in the development of the model as a large rural county with a number of urban centres and a population of around 849,500 (Office for National Statistics (ONS), 2012), covering an area of around 1,010 square miles. It comprises a variety of towns and villages, covered by eight district council areas (Cannock Chase, East Staffordshire, Lichfield, Newcastle-under-Lyme, South Staffordshire, Stafford, Staffordshire Moorlands and Tamworth). Over 17% of the population are aged between five and 19 years (146,300 children).
Methodology: development of a local model
In Staffordshire a model was required to take into account limited pockets of deprivation, the mixed rural and urban nature of the county, and the varying needs across the area while also developing a skill mix workforce. Unfortunately, at the time of the review, no one model met all of these criteria.
A survey conducted on behalf of the Royal College of Nursing (RCN) in 2009 (Ball, 2009) suggested that the average caseload across England is around 2,500, although there are no national standards to determine this. School nurses in NHS Derbyshire County kindly shared their caseload weighting tool (King, 2011) which was reviewed. Unfortunately, it did not completely meet Staffordshire's requirements. The Derby model applies a deprivation weighting that splits teams by high need, average need and low need. On reflection, Staffordshire's population is relatively affluent, with less than a tenth of its population falling in the most deprived areas nationally (South Staffordshire PCT, 2012). This means that slightly more deprived areas may appear to require substantially more school nurses and leave other less deprived areas inadequately resourced to meet the universal demands of the HCP. Therefore, this model was not felt appropriate to use in Staffordshire.
A local model was developed, building on one that had been developed for the north Staffordshire area by the NHS locality manager with responsibility for school nursing, which modelled the expected activity required to deliver the full HCP for five to 19 year olds (NHS North Staffordshire, 2010).
The model involved identifying universal and targeted components from the HCP and estimated how much time each would take. The 2012 School Census was used to identify numbers of children within each school cohort (Staffordshire County Council, 2012). The school nursing service also supplemented the model with local safeguarding data; for example, numbers of looked-after children.
A snapshot of the tool is shown in Table 1. Using the delivery of the National Child Measurement Programme (NCMP) in Year 6 as a working example, it would take five minutes per child to take the height and weight. In addition, the programme requires further administrative resources (for example, letters and telephone calls from parents). The resources for each component were then added up to give an estimated number of school nursing resource in terms of whole-time equivalent (WTE).
The model was circulated to school nurse team leaders to comment on the number of minutes identified activities would take and also the skill-mix. A consensus approach was taken to complete the model locally.
Once the number of minutes was calculated, the annual WTE resource for that component was deduced by basing it on a 37.5-hour average week for 37 weeks. This was based on the assumption that an average school nurse had 13 weeks of annual leave and two weeks of study and/or sick leave.
The model was applied to the eight districts in Staffordshire. This meant that the results could then be triangulated with public health outcomes for children (DH, 2012b; Children and Young People's Health Outcomes Forum, 2012) and profiling data (Figure 1). This was done by looking at public health outcomes for children and current health needs (Figure 2); for example, in Staffordshire there are areas with high health needs for teenage pregnancy and childhood obesity. As the model was applied at a district level, it could be validated by ensuring that the results allocated additional resource into these areas, as per Marmot's recommendations around commissioning universal and proportionate interventions (Marmot, 2010). This also supported workforce planning for the NHS provider.
The average caseload in Staffordshire during 2012 was 2,626, which is slightly above the similar to the RCN average of 2,500.
After inputting local numbers of schools, pupils and safeguarding information the model suggests that the school nursing service would spend around 60% of time on face-to-face activity (eg, immunisation, drop-in clinics or review health assessments); 30% on leadership, management or administrative tasks (eg, identifying local health needs, evaluation, teacher training); and the remaining time travelling around (Table 2).
Findings from the model identified that there would need to be an increase in staffing across all grades, and both clinical and administrative to deliver the required service.
The findings were also compared with the current capacity and other models which are summarised below.
* National estimates--national estimates from the 2009 RCN survey, which found that a WTE qualified school nurse (Agenda for Change, Band 6) has on average 2,500 children on her caseload.
* Derby caseload model--this is based on distributing the school nurse workforce using a weighted population (based on Index of Multiple Deprivation, 2010). The model identifies three different levels of caseload per WTE based on need: low need=3,500/WTE; medium need=2,500/WTE; high need=1,000/ WTE. Only 9% of Staffordshire's population is defined as deprived, but this model is based on a third being deprived. Therefore, this may overestimate the numbers of required WTE within certain areas in Staffordshire.
* Locally developed Staffordshire activity demand model--this is based on calculating the capacity required to deliver the HCP for five to 19 year olds within each district based on the local number of schools, children and safeguarding information.
A comparison of the three models for Staffordshire are summarised in Table 3 and show significant range in estimated number of required Band 6 school nurses based on the three models (47.6 WTE using the average caseload average of 2,500 children to 62.4 using the Staffordshire model to 67.9 WTE using the Derby model). However, all three suggest there is a shortfall in Band 6 school nurses across Staffordshire.
Discussion: limitation of the model
The development of the model has its limitations. These are outlined for consideration as follows.
* Estimated delivery times--calculations made were based on the 2012 School Census and school nurse estimates of time required to deliver various components of the HCP; for example, 15 minutes per immunisation per child. It was also supplemented with local safeguarding data; for example, numbers of looked after children. Estimated levels of activity and time taken to carry out each activity were used following consultation and engagement with various school nurse professionals. A full caseload analysis would have allowed for more accurate results.
* Lack of a full audit--due to very tight time scales for the review, a full audit was not carried out of all school nurse activity across Staffordshire as a whole. A full audit of activity would have allowed for comparison against expected and actual delivery of services to provide a comprehensive gap analysis.
* Varying needs--district and school profile data show the inequalities of children's health and wellbeing needs across Staffordshire. These were used to validate the results of the activity demand tool; for example, those areas with higher needs (higher teenage pregnancy rates, safeguarding) require higher levels of school nursing input. However, as some of the activity didn't have 'real' data, such as mental health needs and behaviour management, each district may not have been adequately adjusted for.
These limitations can be overcome by local commissioners and providers of school nursing services.
A report of the review findings has been produced and serves two purposes:
* To inform commissioners of the current position in relation to the existing school nurse service with key recommendations on what is required to move to a needs-led service
* To assist the local provider in making changes to the existing model and plan for future development of the service. An initial meeting has already been used to review the caseload weighting tool and give the opportunity for team leaders to see the tool in its working format for the first time to localise it further with their teams. The workshop also considered recommendations from the review to plan for future service developments.
The model is now being shared with other local authority areas who are carrying out similar reviews.
With the new arrangements for school nursing strongly embedded in the local authority structures it will become increasingly important to ensure that robust needs assessment models are used to inform the commissioning decisions for the future delivery and design of local school nursing workforces. This model is one such example that provides an evidence base and realistic picture of school nursing provision, identifies gaps in provision, and calculates the shortfall in relation to the requirements for delivery of the Healthy Child Programme that is based on need rather than historical working arrangements. It is a useful tool for collaborative use between commissioners and the school nurse workforce.
* The model uses a health needs assessment approach and brings together key components for consideration: population health data, activity of school nurse workforce, population numbers of school-aged children, a breakdown of components of the HCP and public health outcomes for children and young people
* Application of the model found that there was a shortfall in school nurse workforce in Staffordshire
* The model is very straightforward and it can be practically used and adapted in other areas. It has already been shared with neighbouring council areas and at a regional school nursing conference
* In Staffordshire this is an exciting and challenging time for the service but the model has been embraced by staff who will work to make it succeed
* The model enabled us to provide an evidence base and realistic picture about the current provision of school nursing and gaps in relation to need and for future reconfiguration based on need rather than historical working arrangements
No conflict of interest declared
Ball J. (2009) School nursing in 2009. Results from a survey of RCN members working in schools in 2009. London: Royal College of Nursing.
Children and Young People's Health Outcomes Forum. (2012) Report of the children and young people's health outcomes forum. Children and young people's health outcomes strategy. London: Department of Health.
Commissioning Support Programme. (2009) Good Commissioning: Principles and Practice. London: Commissioning Support Programme.
Department of Health (DH). (2009a) Healthy Child Programme: From 5-19 Years. London: DH.
DH. (2009b) Healthy Child Programme: pregnancy and the first five years of life. London: DH.
DH. (2011) Public health in localgovernment; commissioning responsibilities. London: DH.
DH. (2012a) Getting it right for children, young people and families. Maximising the contribution of the school nursing team: Vision and Call to Action. London: DH.
DH. (2012b) Public Health Outcomes Framework for England 2013 to 2016. London: DH.
King A. (2011) Multi Agency Team (MAT) indicators to determine school nurse allocation (MS Excel-based model). NHS Derbyshire County.
Marmot M, Allen J, Goldblatt P et al. (2010) Fair society, healthy lives: strategic review of health inequalities in England post 2010. London: Marmot Review Team.
NHS North Staffordshire. (2010) School Nursing Capacity Plan. NHS North Staffordshire.
Office for National Statistics (ONS). (2012) Annual Mid-year Population Estimates for England and Wales, Mid 2011. London: ONS.
South Staffordshire PCT, Staffordshire County Council and NHS North Staffordshire. (2012) Staffordshire Needs Assessment: Working together for better health. The Staffordshire Joint Strategic Needs Assessment.
Staffordshire Observatory Council. (2012) Population data from the school census 2012. Staffordshire County Council.
Jo Robins MSc BSc FFPH
Independent Consultant in Public Health
Divya Patel BSc MSc
Senior Epidemiologist (Population Health), Public Health Staffordshire, Staffordshire County Council
Karen Hansford RGN RM BSc(Hons) SPSN
Professional Lead, School Nursing, Staffordshire and Stoke-on-Trent Partnership Trust
Kate Sutcliffe BSc
Public Health Lead, Children and Young People, Public Health Staffordshire, Staffordshire County Council
Andrea Forbes-Westlake BSc(Hons) Dip HE Community Health RGN RM RHV
Public Health Commissioning Manager, Shropshire and Staffordshire Area Team, NHS England
Table 1. Example of the working Staffordshire activity demand model Core Healthy Child Programme activity Activity Number of Cohort minutes Reception screening 30 Reception Year 7 interview 30 Year 7 HPV 15 Year 8 (girls only) BCG 15 Year 9 (targeted only) DTP 15 Year 10 NCMP 5 Reception and Year 6 Total time Activity Activity type AfC band Admin included Reception screening Face to face Band 5 Yes Year 7 interview Face to face Band 6 Yes HPV Face to face Band 5 No BCG Face to face Band 5 No DTP Face to face Band 5 No NCMP Face to face Band 3 No Total time Activity No of children Time in Time in WTE minutes Reception screening 9,097 272,910 3.3 Year 7 interview 8,713 261,390 3.1 HPV 4,468 67,013 0.8 BCG 30 450 0.0 DTP 9,676 145,140 1.7 NCMP 17,483 87,415 1.1 Total time 834,318 10.0 Table 2. Summary of activity demand model for Staffordshire, 2012 Resource in whole-time equivalent (percentage) Core Healthy Child Programme activity 10.0 (12%) Delivery of health promotion programmes 2.2 (3%) Safeguarding activities 16.6 (20%) Teacher training 2.1 (3%) Other activity (drop-in clinics, targeted 36.9 (44%) interventions such as Clinic in a Box, special needs behaviour management, supporting mental health concerns) Public health leadership 6.4 (8%) Travel time 9.1 (11%) School nursing (all grades) 83.3 (100%) Admin support (all grades) 10.2 Table 3. Summary findings from caseload analysis models, 2012 AfC Band 6 Caseload per Difference and over Band 6 WTE to actual resource (WTE) Actual resource 45.3 2,626 n/a Estimated national average 47.6 2,500 -2.3 caseload of around 2,500 Derby model 67.9 1,752 -22.6 Staffordshire activity demand 62.4 1,906 -17.1 model
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|Title Annotation:||PROFESSIONAL AND RESEARCH: PEER REVIEWED|
|Author:||Robins, Jo; Patel, Divya; Hansford, Karen; Sutcliffe, Kate; Forbes-Westlake, Andrea|
|Date:||Feb 1, 2014|
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