The Education Act of 1907 gave local education authorities the duty to provide for the medical inspection of children at admission to public elementary school and on other such occasions as the board directed (Harris 1995). This was a medical model of care, based upon screening, which showed up many clinical problems. But these were the days before the National Health Service (NHS), and so effective treatment was not available to all families, although school nurses were expected to do home visits and ‘follow up’ children, especially in regard to hygiene issues. Furthermore, schooling was not compulsory or accessible to every child until after the 1944 Education Act (Department of Education 1944), which also placed a duty on local authorities to contribute towards the mental and physical development of children. The doctor-led school health service was transferred to district health authorities under the NHS in 1974 and from this time became more universal. It was still a screening service but by now it encompassed vision and hearing tests, height and weight recording as well as immunization. Further Education Acts in 1981 (Department of Education 1981) and 1993 (Department of Education 1993) placed a statutory requirement on local education authorities to notify health services when a child needed special services in order to access education. This multiagency working has continued and expanded. Gradually the school nurse service has moved from being a task-orientated service that adopted a medical model approach to service delivery, to a public health social model approach, using health education and promotion alongside clinical interventions to improve the health of the school-aged child. School nursing is not, and has never been, the same service across the UK, and now with the four countries developing their own health services, the situation remains diverse.

The policy drivers behind school nursing in England are Every Child Matters (Department for Education and Skills (DfES) 2003); the National Service Framework (NSF) for Children, Young People and Maternity Services (Department of Health (DH) 2004a); Choosing Health (DH 2004b) and the Healthy Living Blueprint for Schools (DfES 2004). The Children Act (2004) provides the legal underpinning for the Every Child Matters: Change for Children (DfES 2003) programme in England and Wales. It places a legal duty on local authorities to cooperate with statutory bodies (e.g. police, probation, Connexions, NHS) to develop a single children’s plan, based on the five outcomes: be healthy; stay safe; enjoy and achieve; make a positive contribution; achieve economic well-being. This is the basis for children’s trusts. The Childrens Plan (Department for Children, Schools and Families 2007) has brought these and other guidance into one document.

Currently many PCTs are undertaking service redesign in order to align school nurses more closely with health visitors and other primary care staff in children’s trust formats. Children’s trusts are multiagency working agreements to deliver the outcomes of Every Child Matters (DfES 2003). They can be ‘virtual’ arrangements or properly constituted trusts; each area can decide how to do this.

The NSF (DH 2004a) is a model of assessment and early intervention to improve health outcomes, which extols the role of school nurses as they play an essential role in promoting the health of school-aged children, and providing confidential healthcare advice and support. School nurses are part of a team in schools who can support the attainment of national targets such as those on child and adolescent mental health services, teenage pregnancy, child obesity and school attendance (DfES, DH 2006b). It flags up the certificated training for Personal, Social and Health Education (PSHE) which is available to all community nurses so that they can help deliver PSHE in schools (National PSHE CPD Programme 2008). The NSF (DH 2004a) states the Chief Nursing Officer’s (CNO) recommendation of a minimum of one full-time, whole-year, qualified school nurse in every secondary school and its cluster primary schools, to lead the delivery of effective public health programmes and states that additional funding has been made available to PCTs to employ additional school nurses where needed.

The Healthy Living Blueprint for Schools (DfES 2004) includes school nurses among other health promotion staff and reiterates the CNO’s recommendation to increase numbers. Choosing Health (DH 2004b) heralded an enhanced role for school nurses as leaders to support the health environment of schools, and again mentioned new funding which had been given to PCTs so that they could employ extra staff. School nurses would have roles in early detection and prevention and referral of problems, and health promotion regarding sexual health, obesity and mental and emotional well-being. The tool for this would be children’s health guides; an extension of the Personal Child Held Record (known as the ‘red book’), which the parent would fill in with the child, who would increasingly take responsibility for his/her own health, in conjunction with advice and support from the school nurse. The CNO would lead work to modernize and promote school nursing and develop a national programme for best practice.

The deputy CNO did indeed undertake a review of school nursing with stakeholder involvement which resulted in Looking for a School Nurse (DfES, DH 2006b). This non-statutory guidance was intended for head teachers and school governors to explain the skills and services which school nurses can bring to schools and the potentially improved health and well-being outcomes for pupils. However, as schools do not directly employ school nurses, and do not usually put aside any funding to do so, it was limited in use. At the same time the School Nurse Practice Development Resource Pack (DfES, DH 2006a) was republished. This gives lots of practical advice to school nurses to improve and define their practice in order to ‘sell’ their service to schools.

There are significant public health problems in Scottish children and young people: risk-taking behaviours such as smoking, drinking alcohol to excess and drug taking; teenage sexual health and pregnancy; poor dental health; obesity; lack of exercise, etc. (Scottish Executive 2007). The policy background for children’s health services in Scotland is Getting it Right for Every Child (Scottish Executive 2006a). This sets out a programme of reform placing a duty on statutory agencies to enhance cooperation and information sharing and develop integrated service plans, putting the needs of children at the centre. Delivering a Healthy Future (Scottish Executive 2007), the action framework, states that services must be designed to protect and promote health as well as treating disease, targeted to the health challenges of the 21st century, and equitable across the country.

All schools in Scotland should be Health Promoting schools (Barnekow et al 2004). This overarching programme covers physical and emotional health and well-being in a whole school dimension. However, these initiatives have shown up the problem of a lack of children’s health workforce across primary and secondary care, especially Child and Adolescent Mental Health Services (CAMHS). Scotland is now trialling a community health nurse role (Scottish Executive 2006b) which will be a combined health visitor/school nurse/district nurse public health job. This will need new university training courses to be developed, alongside existing training courses, and will need extra funding from health boards. It is difficult to see how one nurse could fulfil and maintain the competencies to the required standard across such a wide spectrum of work. Some community health partnerships have decided to keep the different public health nurse disciplines separate as before, so there is a patchwork of services across the country.

A review of school nursing in Wales (Allen et al 2004), based on representative sample data, showed an ageing, underdeveloped, under-resourced service, with disparity of practice and lack of policy direction. This was followed by a re-examination of the review of health visiting and school nursing undertaken by the National Assembly for Wales in 2000 (Irvine and Kenkre 2004). The recommendations included:

The Welsh government has committed to provide a minimum of one ‘family nurse’ per secondary school by the end of the assembly term (Welsh Assembly Government 2007) and has consulted with stakeholders regarding the scope of this role, which is an enhanced school health nurse reaching out to families and the community.

The Department of Health, Social Services and Public Safety (DHSSPS) in Northern Ireland commissioned a report on community health nursing (DHSSPS 2003) to review the current practice and possible future direction of the services. School nurses were found to have low status and low staffing levels (only 93), but no specific plans were identified for them.

All four countries are reviewing their school nurses, with the aim of involving them more in public health work streams. However, these plans have become tied up with the CNO’s Modernising Nursing Careers (DHSSPS et al 2006) programme, which suggests generic roles rather than specific ones, with skills and competencies as the benchmark for employment, and not a specific school nurse qualification. This is a joint project with each country leading on a specific theme, and will result in new training routes and possibly better career progression.

Meanwhile, NHS workforce census figures show that there are only just over 1000 whole-time equivalent qualified school nurses for over 3000 secondary schools in England. Even taking into account other registered nurses working in school health teams, the total numbers remain disappointing at around 2000 whole-time equivalent nurses. These numbers include those registered nurses who only work in special schools, so the numbers available for mainstream schools are under 2000. The result is that school nurses are increasingly frustrated because they are unable to perform their public health functions owing to over-large caseloads, while all the time schools and PCTs find new streams of work which they should do (Ball and Pike 2005) (see Chapter 23 for further information on barriers and facilitators to nurse practice in public health). In many areas their involvement in health promotion activities has ceased as resources have been diverted to the National Child Measurement Programme and new immunization schedules. This has dire consequences, as England is forging ahead with commissioning of primary care services, and school health teams will be expected to produce results in line with Every Child Matters outcomes (DfES 2003) and government and local public service agreement targets. Contracts are being framed within the current under-resourced climate and it is difficult to see how the ‘step change’ in public health outcomes for school-aged children can be achieved.