Organisation submitting example
Derbyshire County PCT
Local authority/local area:
The context and rationale
The school nursing resource allocation was based upon the guidance of one fte Qualified School Nurse per Secondary School and its cluster. This resource did not reflect the differing needs of the schools and localities. The Matrix took into account a range of deprivation factors and public health outcomes and allocated the school nursing resource on the basis of need.
Background details to your example
The experience of developing a new specification for health visiting and the allocation of the Health Visitor (HV) as a resource to primary care teams influenced how to take forward the redesign of the school nursing service. Previously allocation of health visiting was based upon ‘custom and practice’ as is school nursing.
The overall aim was to find a way of establishing an equitable delivery of the school nursing service according to need and to develop the school nursing service into a provision that was fit for purpose to meet the changes and demands of an integrated provision.
Driver(s) for action
1. The local review (linked to the National Review) of school nursing.
2. The lack of clarity that surrounded the role and function.
3. The uncertainty of the outcomes for school nursing.
4. Cost efficiencies.
5. Integrated working agenda.
Milestones to Achievement
• Agreement with the local authority in terms of how the school nurse contributes to improving the educational attainment of children and young people though supporting every child to achieve their health potential.
• Alignment of the school nursing provision to the multi-agency teams.
• Review of school nursing outcomes in relation to current requirements.
• Development of a new service specification that was explicit in the areas of work to be covered.
• Acknowledgement that in areas where there are higher deprivation indicators the school nurse resource should be higher; this drove the development of the School Nurse Matrix to identify resource allocation.
• The school nurse matrix is purely a simple graphical picture of all the key indicators that contribute to a school’s (and community’s) deprivation levels. The indicators were chosen because they were the key indicators that school nurses could directly contribute to.
• The matrix was broken down into high, medium and low need on a basic level as a measure of expressing where the resource should be the greatest.
• The indicators were already in the Health and Local Authority information systems, and therefore easily accessed. Some were based upon annual change and others, because of small numbers, would be quantified on a 3 year basis.
• In the absence of any clear guidance, the allocation of the school nurse to the resource took the principle of one Qualified Specialist Public Health School Nurse per secondary school and its cluster and evaluated what that looked like in Derbyshire. There was a significant variance with the cohorts with no rationale as to why a school in an affluent area should have the same as a school with high needs.
• The caseload allocation is a guide and by no means fixed, but a trial to assess if this ratio is successful in relation to delivering outcomes.
Work will take place on assessing the Derbyshire average against each indicator and a baseline will be drawn which the targets should not fall below. This will accommodate the fluctuation of schools from high – medium – low more easily.
The step by step process is shown below.
1. Identification of the key relevant indicators that school nursing service contributes to or leads upon.
2. Consultation with School Nursing, multi-agency teams, and schools as to the value of the matrix and its acceptability. This resulted in several amendments (nine in all) and in particular it highlighted the high priority and needs of Special Schools, Support Centres and the numbers of children not in mainstream education.
3. How to assign ranking was a major difficulty and very complex, so it was decided to put a high, medium and low ranking to be consistent with deprivation needs and the collective high ranked targets.
4. All the variables were gradually built up to form the picture presented on the matrix (please contact the C4EO team at the NFER if you would like to view this document).
5. Public Health Practitioners, Public Health Analysts, Local Authority Analysts, and School Nurses discussed the process and how it could be applied.
6. The matrix will be in place by April 2012, and the targets reviewed annually or every three years as aggregated figures or as appropriate. The Multi-agency provision (MAT) will, with the School Nursing Service, review where they are and how the different contributions can be directed to improve outcomes for children and families. As part of this, there is a newly formed Locality Planning and Commissioning Forum that will help redirect resources to the point of need.
7. Indicators can be changed in relation to need and targets.
• It is anticipated that the school nurse reallocation of resources alongside the acceptance of the new School Nursing specification (please contact the C4EO team at the NFER if you would like to view this document) will commence April 2012.
• Each year there will be a review of the indicators and agreement in relation to the key objective set to support improving outcomes for children.
Achievements so far
The measures of success will be:
1. The matrix and the school nursing specification have been agreed by the providers and multi-agency teams as reflecting good practice.
2. The success will be in the identification of individual indicators and monitoring their improvement.
3. The redesign of the school nursing service aligned to work against key targets and integrated working. The overall measurement of success is improved outcomes for children, of which the targets within the specification and matrix are contributors. Improved school attainment is a good measure also.
• The only current evidence is the recognition that there needs to be a needs-led approach to resource allocation.
• School nursing provision welcomed the matrix and the comprehensive service specification to enable them to shape their provision more effectively.
Organisation and/or cultural change
• This will be a significant factor in moving school nursing from an established way of working to a focused service with clear parameters. To achieve this we have learnt from the health visiting transformation that a new specification on its own will not change practice, but clear pathways, good leadership, and chipping away at the benefits of multi-agency working and clear definition of roles will work.
• A more effective and efficient service responsive to need.
Service alignment and integration can be complex and be a challenge for those resistant to change.
The only solution we can think of is to promote those areas where the change is working well, and keep influencing the areas where greater support is required to affect change.
It is anticipated that the resource currently will stay within the same financial envelope. However this is the first transitional change, and as the new specification and needs-led working begins to demonstrate effectiveness, or difficulties within delivery, the service will be reviewed by contract variation. It is anticipated that there will be cost efficiencies through working in a multi-agency team setting.
Advice to others/learning from the experience
Provide constant explanations as to the rationale for change.
Keep people informed of the process, providing proactive response to questions, and meeting services half-way in the process of change to provide details of what can be accommodated.
Key leadership behaviour characteristics
The following core behaviours have been identified as part of successful elements of leadership (see National College for Leadership of Schools and Children’s Services/C4EO (2011) Resourceful leadership: how directors of children’s services improve outcomes for children. Full report. Nottingham: NCSL.)
Derbyshire identified the following behaviours as key to the transformation of their service:
openness to possibilities
the ability to collaborate
The design of the matrix was to encompass both a needs-led and measurable outcome model, where new data was already within the system. This would enable the school nurse and the wider multi-agency team to collectively measure their trends and successes, as well as be in a position to focus upon the results, and set locally determined objectives. The Matrix can be subject to change as new needs / outcomes are identified. It is readily understood, by all agencies, and is a tool by which the school can benchmark itself. It can be easily maintained and updated.
the ability to create and sustain commitment across a system
focusing on results
the ability to simplify
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