Healthy Child Wales Programme: for school aged children

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.

Purpose and aims

The purpose of the school entry health review is to:

• assess the child’s health needs
• promote public health and wellbeing
• support and enable children to achieve their full potential
• transfer care from health visiting to school nursing services

All school aged children will have access to a named specialist community public health nurse (school nursing) who can be contacted for advice and support.

All children at 5 years of age with an identified outstanding health need, such as outstanding immunisations, will have their care formally transferred over to the named nurse in school nursing services by the health visitor.

All parents/carers of children aged 5 years old will receive a digital school entry information welcome pack during their first term. The school will be asked to distribute the digital packs to all children attending schools.

Any child electively home educated will receive the welcome pack from the school nursing service, introducing the service and providing the digital welcome pack through an appropriate method.

The digital pack will include:

• an overview of the school nursing services
• a welcome letter for the parent/carer including:
  • a school nursing services leaflet, including link a to welcome videos
  • information of who the named specialist community public health nurse (SCPHN SN) will be and how contact can be made
  • information of who the nurse in special schools will be and contact details
  • details about how families can access the school nursing services websites
  • useful links and digital leaflets
• information on:
  • 10 steps to a healthy weight
  • height, weight and vision screening including how results will be shared and can be accessed
  • healthy lunch box, importance of hydration/nutrition
  • school aged immunisation programme including consent process
  • child measurement programme
  • how parents can opt out of height, weight and vision screening and child measurement programme

Information will be shared between the health visiting and school nursing services to ensure a smooth transition into education, regardless of setting.

All children are assessed by the health visitor and have a level of care assigned to them. Any children with an enhanced or intensive level will have their care formally transferred over to the named specialist community public health school nurse at the age of 5.

For children in special schools, the nurse in special schools will be responsible for the care co-ordination. Where there is not a nurse based in a special school, the care co-ordination role will be transferred to the child disability team.

The health visitor will inform the family that care is being transferred to school nursing services when their child reaches 5 years of age. The health visitor will also provide details to parents/carers of how they can access and contact school nursing services.

Children and young people educated other than at school or electively home educated should be transferred to the appropriate named nurse within school nursing services.

Children entering special schools may start school before 5 years of age. Health visiting services will remain the caseload holder for these children until they reach 5 years of age, when care will be transferred to school nursing services. The nurse in special schools will work in partnership with the health visitor and community children’s nursing services to ensure their care is co-ordinated.

Children and young people with complex healthcare needs will be supported by a care co-ordinator within school nursing services. Care co-ordination will be offered to all school aged children and young people with complex healthcare needs and with an identified level of care of enhanced or intensive.

The aim of care co-ordination is to proactively identify and work with other professionals to make the right connections leading to providing the most appropriate care at the right time. This includes supporting the child / young person and parents/carers to navigate the health and care system, so they become more active in managing their own healthcare needs where possible. The care co-ordinator is skilled in assessing and responding to changing healthcare needs and again co-ordinating support to manage changes.

All children will have their immunisation status reviewed to ensure they have accessed the full pre-school childhood immunisation programme. School nursing services will ensure families are made aware of how they can access any outstanding immunisations.

All parents will be provided with information on the growth screening programme and the national vision programme for all children aged 4 to 5 years of aged (reception year) including their height, weight and vision.

All children attending a reception class in any school in Wales, including maintained and independent schools, are eligible for screening.

Children who miss the screening in reception for any reason will be offered "catch-up" sessions in year 1 by school nursing services.

Children who are educated other than at school or electively home educated will be signposted to GP services and opticians by school nursing services through the welcome pack.

In most cases in Wales, hearing screening (also referred to as audiology) is not managed by school nursing services and therefore is outside the scope of the new operating model.

Universal

School nursing services will assess risk, based on the information they have obtained from transfer of care by health visiting services.

School nursing services will review any documentation transferred by the health visitor relating to the child and act upon any outstanding public health needs (for example outstanding childhood immunisations).

Advice and support will be offered if concerns are reported or identified.

Information will be provided to parents on the growth and vision screening programmes, including how to access measurements taken or opt out. 

Advice and support will be offered to all families in line with pathways.

Children and young people in special schools assessed as needing a universal level of support will require low intensity care co-ordination. This will focus on the nurse in special schools working in partnership with the specialist community public health nurse (school nursing) to ensure delivery of the operating model.

Enhanced

Children identified with a body mass index (BMI) equal to or above the 91st centile will be followed up by school nursing services in line with the weight management pathway and will be offered further support, signposting and referrals made where appropriate.

A health assessment may be undertaken if appropriate with parental consent.

Parents will be invited to discuss their child’s health and wellbeing needs during his process.

If the health board has a weight management service, details of how a referral can be made to them will be shared with parents or alternatively made by professionals.

Targeted public health sessions to schools/communities will be offered where health needs are identified from results and trends.

Children and young people requiring additional intervention will receive individualised additional support, early intervention following identification of additional needs, and/or episodic management of needs.

Intensive

School nursing services will work alongside other agencies in line with the Wales safeguarding procedures when outstanding health needs are handed over from the health visitor or new concerns are identified.

A health assessment will be carried out if safeguarding concerns are highlighted.

Referrals to appropriate specialist services will be made according to need, for example to a dietician.

School nursing services will support children, young people and their families who have more complex health needs and those with additional health needs identified during screening. This will include a health care co-ordination role to ensure the health needs are met in line with the relevant height, weight, vision pathway.

Children and young people requiring an intensive level of support will often have multiple complex health needs and psychosocial risk factors, for which they require specialist support. They will often have multiple services involved in their care and care co-ordination will have a higher level of intensity.

The care co-ordinator will be critical to leading on a shared plan of care to meet the child’s health promotion and protection needs in addition to their chronic condition management.

In addition to the screening for height, weight and vision at school entry, school nursing services also support the work led by Public Health Wales to monitor the longer-term trajectory of children’s growth development (height and weight).

Through the child measurement programme, all children that attend reception class, including maintained and independent schools, will have their height and weight measurements taken in line with the national standards for the national programme.

An assessment of the health and wellbeing needs of children and young people is an important starting point to plan services to improve health and wellbeing during school age. The focus is the population of children and young people for the cluster of schools that school nursing services has responsibility for, rather than a health needs assessment for every single child or young person.

When undertaking population health needs assessments, professionals working in school nursing services understand the strengths and challenges to health and wellbeing in the population. This includes the identification of the additional needs of vulnerable groups such as:

• children in care
• travellers
• refugees
• asylum seekers
• those with complex health needs

School nursing services raise awareness of the needs identified locally, for example through drop-in attendance, and support the development of universal or targeted public health interventions in partnership with other professional disciplines and agencies.

School nursing services will undertake a population health needs assessment for each of the cluster of schools they are allocated. The assessment will consider the health needs of all school age children and young people, regardless of setting.

The population health needs assessment will be completed annually during the first term of the academic year (September to December). This enables school nursing services to take account of other information sources held by schools and other public services, for example wellbeing assessments, which are produced by public service boards in Wales. These assessments need to be reviewed annually to reflect any emerging public health concerns or issues. There is a wealth of quantitative and qualitative data available to school nursing services about the health of the local population that can be narrowed to the local area and compared to regional and national data for comparison and benchmarking.

Some example indicators are:

• children in poverty (under 16 year olds)
• immunisation uptake
• dental extractions
• childhood obesity
• admission episodes for alcohol-specific conditions (under 18 year olds)
• smoking and vaping rates
• teenage pregnancy rates
• absentee rates in education

Using the population health needs assessment, school nursing services will ensure effective planning, development and delivery of services to improve public health and wellbeing outcomes for the target population. In line with the operating model, key high impact areas which reflect the population health need will be prioritised and identified.

Whilst being led by school nursing services, this approach supports collaborative working and integrated delivery. It will be delivered by teams with different skill mixes, with health workers working alongside other members of the wider NHS Wales and public service workforce.

Who is most at risk

High impact areas are those where the biggest difference can be made to children and young people’s health through the delivery of the operating model. This can be wide ranging and dynamic as public health issues change and new challenges emerge.

Children and young people with complex health needs are at risk of poorer health and wellbeing outcomes, although this risk will be influenced by multiple protective factors such as a supportive family dynamic. This includes children and young people with:

• physical disability
• learning disability, autistic spectrum disorder and neurodiversity
• emotional distress
• other vulnerabilities
• looked after children

Compiling a health needs assessment is a tool for school nursing services to gain a more in-depth understanding of their population and the needs that exist, with the goal of enabling more effective planning, prioritisation, and subsequent delivery of services to improve outcomes for children and young people. These high impact areas can include:

• health behaviours and lifestyle
• smoking and vaping
• sexual health
• building resilience
• reducing risk behaviours
• children and young people with complex health needs

Children and young people with more complex health needs will require an individual health assessment. This will be completed if unmet health needs are identified at school entry, or thereafter, and reviewed annually. The health assessment will be nurse-led but involve close engagement with the parent/carer utilising the wider team around the child approach. Every child and young person in Wales identified with enhanced or intensive level of care will have a care co-ordinator assigned to them by NHS Wales.

Within the implementation period, an all Wales standardised health assessment for children and young people with complex healthcare needs will be developed. This individualised assessment will cover a chronology of health events, family relationships, identified health needs, including public health needs and focus on the child or young person’s strengths and vulnerabilities.

The completed assessment undertaken in collaboration with parents/carers, along with reports from other professionals, will enable school nursing services and the team around the child to develop a healthcare plan for the child / young person with complex needs. This should include establishing what is important to the child and parents/carers and understanding their goals. Training, guidance and support for children and families with complex and long-term health conditions will be planned and facilitated by the team around the child, with school nursing services leading on care co-ordination.

The operating model is the national evidenced-based universal provision for school aged children, as part of the Healthy Child Wales Programme. The level of intervention, whether universal, enhanced, or intensive, will be defined by the population, community and individual needs assessments carried out by school nursing services. All school aged children are offered universal services. Children and young people with enhanced or intensive levels of health need are offered additional support to meet those needs.

Universal

Core components of the operating model available to all families with children / young people between the age of 5 and 16 years of age will include:

• health and development
• school entry health review
• screening and surveillance

Immunisations will include:

• specialist community public health nurses (school nursing) can offer information on key public health messages including immunisations
• school aged immunisation programme

High impact areas, guided by the population health needs assessment, include:

• hydration
• nutrition
• smoking/vaping cessation
• infectious diseases
• healthy lifestyle choices

Safeguarding includes:

• early detection / awareness of adverse childhood experiences

Emotional health and wellbeing includes:

• healthy relationships
• puberty and growing up / hygiene / body changes including periods and pelvic floor
• transition support at key points including:
  • nursery to reception
  • year 6 into secondary school
  • transition into adulthood
• school based drop-in sessions
• emotional health and wellbeing support

Relationship and sexuality education includes:

• sexually transmitted infections
• contraception
• condom distribution scheme

The universal offer will continue to be offered and provided with adjustments made as appropriate based on individual health assessments for children with complex health needs.

Enhanced

The enhanced level of support will include a more predicted, assessed and expressed needs-based approach with early interventions to promote positive outcomes. The targeted public health support is provided throughout the compulsory school age for children / young people aged 5 to 16 years old (years 1 to 11).

It also provides targeted, evidence-based support for children and young people in the following areas.

Under health and development, the enhanced level of support will provide:

• health assessments (to identify unmet health needs)
• follow up from school entry health review/screening and surveillance/referral to specialist services

Regarding immunisations, the enhanced level of support will:

• assist in school aged outbreaks/pandemics, for example, polio or measles outbreaks, working with partner agencies

Public health includes:

• nutrition and weight management
• bladder and bowel health
• dental health
• substance misuse
• referral to specialist services

Emotional health and wellbeing includes:

• emotional health and wellbeing one to one support
• referral to specialist services

Safeguarding concerns includes:

• health assessment to identify unmet health needs
• referral to specialist services

Regarding sexual health, the enhanced level of support will:

• signpost for further support or refer to specialist services

Children and young people with complex needs can experience anxiety and low mood due to feeling different from others and their emotional mental health can be further negatively affected due to their physical health needs being the focus for professionals. They may have learning and/or communication difficulties. It is also evidenced that children and young people with complex health needs and disability are at a higher risk of abuse. Therefore, in recognition of the additional healthcare needs and risk, face to face drop-in sessions in special schools will be offered. Where required, school nursing services will seek advice from learning disability nurses, to support necessary adjustments in delivery of these sessions.

School nursing services will work in partnership with parents/carers and the team around the child, to support the high impact areas and individual health needs identified. This may include liaison with learning disability nurses and wider services. The child may be able to be stepped down to the universal pathway once needs are supported.

Intensive

The decision to provide this highest level of support is guided by the individual healthcare assessment and overall complexity/intensity of health need. As a result, identification of intensive need may include:

• referral to specialist services
• safeguarding concerns
• wrap around support for the child and family with the school nursing services undertaking higher intensity care co-ordination within the wider team around the child
• family centred holistic care and support may be required to support resilience of the whole family, with multi-agency input and specialist referral

Why it's important

A key role of school nursing services is to support children as they move through the different stages of school life, such as starting school for the first time, or moving from a primary school to secondary school. Referred to in public services as ‘transitioning’, these key stages in a child or young person’s life are critical opportunities to support ongoing development and wellbeing. The transition points are different for children and young people who are educated in settings other than at school or special schools. However, transition points remain in curriculum or development terms, even though the setting may not change. For example, some children / young people educated at home during primary years may transition to mainstream secondary education.

Therefore, transition points in a child / young person’s education refers to a significant time where a child moves from one educational level and/or setting to another.

Supporting children / young people and parents/carers to think about how they manage their own/child’s behaviour is part of the school nursing services role. They will provide support through a number of approaches, such as:

• group work
• one to one sessions
• class-based activity 

They will deliver public health sessions to discuss these topics and provide information to encourage children and young people to make informed healthier choices through their journey through the school stages, regardless of setting.

We look at the key transition points for school-aged children in the next sections.

Transition can be an exciting time for children, but it can also be a challenging time for some children who may need some additional support as they become more independent from the family and develop their learning potential including how to socialise with others.

Working with other professionals, such as health visitors, will be key to identifying outstanding health needs to ensure seamless transition and flow into school nursing services and make sure continued support is provided to the child and family. This is covered in detail in the school entry health review section of the operating model.

All children aged 5 years old will have a school entry health review, as part of the review delivery will be transferred to the school nursing services from the health visiting service. Services will be provided by school nursing services will be offered through a tiered level of public health interventions based on need.

As children and young people move into and through secondary school age, many of them will be entering puberty. Puberty and the changes that occur during this time, both emotionally and physically, can prove to be particularly challenging. Children and young people may begin experimenting with risk taking behaviours such as:

• vaping
• smoking
• alcohol
• substance misuse
• unhealthy relationships

As they learn to adjust and manage these hormonal changes, they are also more vulnerable to experiencing anxiety, issues with low self-esteem and may begin self-harming behaviours as a coping mechanism.

School nursing services will provide information through a variety of digital channels to all children in year 6 approaching 12 years old. The information will include:

• how to access the specialist community public health nurse (school nursing) at drop-in sessions
• immunisation schedules
• building healthy relationships
• dealing with stress and new environments
• emotional and physical changes through puberty
• hydration and nutrition
• how to reach out to appropriate professionals for advice

School nursing services will provide regular support, information and advice to young people through a number of digital channels to educate, inform and support them to make healthier lifestyle choices.

Upon commencing secondary school education, school nursing services focus will be on supporting children and young people with the transition and healthy relationships. The emphasis will be upon the children and young people taking responsibility for their own health across the following areas:

• emotional and physical changes through puberty
• healthy relationships and lifestyle
• importance of self-examination
• accessing confidential drop-ins

Prior to the young people finishing formal education at 16 years old, information will be shared with young people, aiming to prepare them for their next steps in life. This is key to ensuring that young people are able to take control of their lifestyle choices and understand how to reach out for help. Topics covered include:

• how to access sexual health advice
• consent in relationships
• accessing GP or 111 services for advice and accessing their immunisations records
• accessing mental health support if needed

Some children and young people will require a higher tier of support during school transitional stages. This may be due to existing emotional wellbeing needs, other vulnerabilities, or complex healthcare needs which can increase the impact of changes such as puberty which has been described above.

Within this operating model school nursing services will work in collaboration to assess a child’s need and agree how the public health classroom sessions are delivered across all schools. In special schools, some children and young people may be able to engage in classroom-based sessions with the use of visual materials and adaptations but others will not. Therefore, the delivery will be tailored accordingly based on need from school entry onwards. Nurses working in special schools will work within a team around the child model to support the adjustments required. Liaison with parents/carers is key to this.

Children and young people with complex needs can be more sensitive to changes in faces, structure, routine and environment. Nurses working in special schools will support the school to manage the child / young person’s health and wellbeing needs during school transitions. The care co-ordination role, which the nurse in special schools undertakes, is important to support person centred planning and continuity of care and promote information sharing between services. Meetings should be held at least 8 weeks before a transition takes place (for example, change of a school year) if it is anticipated that the child or young person is going to need additional support.  Multidisciplinary planning is key to providing a better transitional process and reducing anxiety for children, young people and their families and reducing any adverse impact on the child’s health and wellbeing.

As in mainstream settings, the aim as the child / young person reaches puberty is to promote their understanding of risks and empower them to make self-informed healthier lifestyle choices. Supporting the child or young person to develop self-care, adapted to recognise either their healthcare and wellbeing needs whilst improving their independence, is important as they develop into adolescence.

Some young people will require an ongoing care and support package from health or social care services following their 18th birthday. Transition from children to adult services is a complex process and planning should start as early as 14 years old. In line with their care co-ordination remit, it is important for the nurse in special schools to link with the professionals leading on the young person’s transition planning and establish if a transition co-ordinator has been assigned. The young person will be known to local community children’s nursing services or children’s learning disability services and may have an existing social worker with the local authority children’s services.

The specialist community public health nurse (school nursing), will provide confidential drop-in sessions for children at all mainstream secondary schools. These drop-in sessions will be held weekly on a secondary school site during school term and during school hours. These drop-ins provide a confidential space where children and young people can feel comfortable to discuss personal health or emotional concerns. All secondary school children and young people can access this drop-in confidentially. For children educated other than at school, alternative convenient venues will be available for children and young people to access, for example, coffee morning sessions with families, community drop-ins, advertised through digital channels.

School nursing services are trained to have an awareness and to identify where issues may be more complex and be able to support, signpost and refer children and young people to other more appropriate services. This approach fosters trust and encourages open communication, allowing early identification and support to be provided appropriately.

Children and young people have voiced that it is extremely important to have consistency of the same specialist community public health nurse (school nursing), for the weekly drop-in sessions, as they feel this enhances the effectiveness of the support. It builds trusting relationships between the child / young person and the nurse creating a comfortable environment for open communication. This continuity allows the nurse to better understand the child / young person’s needs and provide more personalised support over time. This includes avoiding the need for children and young people to retell their story to multiple professionals, which is often a barrier to young people seeking support in the first place.

Confidentiality within these drop-in sessions is crucial for creating a safe space and information exchange. The specialist community public health nurse (school nursing), working within safeguarding policy and guidance will ensure confidentiality remains, except in exceptional circumstances where there is a risk of harm. This confidentiality helps build trust and encourages children to share their concerns openly with the assurance that their privacy will be observed.

As part of the drop-in sessions, school nursing services will provide support and discussions around sexual health. The nurse will provide valuable information on topics around puberty, relationships, and safe practices. These conversations empower young people to make informed decisions about their health and wellbeing. It is vital through these sessions the nurse provides a safe and non-judgmental environment for children and young people to ask questions and seek advice and guidance. Access to the condom distribution scheme will also be available through the drop-in sessions.

School nursing services will provide a single point of access for parents/carers and families to access advice and support. This approach will enhance efficiency and ensure families are easily connected when the assistance and advice is needed. The single point of access information will be provided to all families through the school entry welcome pack.

Ensuring children are offered and receive vaccinations is a fundamental aspect of public health. It helps to promote individual wellbeing and community resilience against preventable diseases in line with the children’s routine immunisation schedule for all children in Wales.

School nursing services, in line with the school nursing framework for Wales, will deliver the school-based programmes to all pupils in line with the standards.

Key public health messages will be delivered to eligible pupils in school during the year the vaccinations are due. By incorporating age appropriate and accurate information, school nursing services can empower pupils to make informed decisions about their health and wellbeing. Pupils will learn how vaccines protect them from specific diseases, promoting a proactive approach to their own health.

Assessment of immunisation status of all children at school entry

The vaccination status of every pupil will be checked at entry to primary school to ensure each pupil is up to date with the UK schedule for routine childhood immunisations. Information will be offered to families about how to obtain the outstanding vaccinations.

Intranasal live attenuated influenza vaccine (LAIV)

Intranasal live attenuated influenza vaccine (LAIV) will be offered to all eligible pupils in school in the autumn school term.

Assessment of immunisation status of all children at secondary school entry

The vaccination status of every pupil will be checked at entry to secondary school to ensure each pupil is up to date with the UK schedule for routine childhood immunisations and information offered about how to obtain the outstanding vaccinations.

National standard that all eligible pupils in school year 8 are offered the HPV vaccine

All eligible pupils in school year 8 will be offered the HPV vaccine.

All eligible young people in year 9 are offered the Td/IPV and MenACWY vaccines

All eligible pupils in school year 9 will be offered the Td/IPV and MenACWY vaccines.

The Td/IPV vaccine, also known as the "teenage booster" or the "3 in 1", is given to boost protection against 3 separate diseases:

• tetanus
• diphtheria
• polio

It's a single injection given into the muscle of the upper arm.

The MenACWY vaccine helps protect you against 4 different causes of meningitis and septicaemia: meningococcal groups A, C, W and Y disease.

Opportunities will be provided for catch up vaccination for those who miss scheduled vaccinations

Opportunities will be provided for catch up vaccination for those who miss scheduled vaccinations to protect against seasonal flu, the human papillomavirus virus, tetanus, diphtheria and polio and meningitis and septicaemia (Fluenz, HPV, Td/IPV and MenACWY).

Our approach

As part of a wider NHS Wales and multi-agency response to safeguarding, school nursing services play an important role in in promoting, protecting, and safeguarding the health and wellbeing of children and young people. The approach to safeguarding for school nursing services was established through a set of minimum standards in the school nursing framework 2017 and health boards have monitored compliance with these standards and alignment to the subsequent multi-agency all Wales safeguarding procedures 2019.

School nursing services have a population health approach to delivery, which means they do not hold a case load in the same way that other health professionals do, such as health visitors or other public service practitioners, like social workers. What this means in practice is that a child / young person with a safeguarding concern might not be known to school nursing services. Therefore, it is important that NHS Wales identifies the correct health lead at an early stage to provide the best NHS Wales safeguarding response. For the purpose of this operating model, the following pathway has been developed to support the existing minimum standards in the school nursing framework. This will help to make clear what school nursing services will deliver in relation to safeguarding for those specific cases when school nursing services is correctly identified as the NHS Wales lead, due to their knowledge and/or ongoing involvement with a child or young person and their family.

In line with the Healthy Child Wales Programme, all children at 5 years of age with safeguarding concerns will be highlighted to the school nursing services, when they are transferred during the school entry health review.

Where new safeguarding concerns have been identified during a child or young person’s journey through school age, school nursing services will undertake a health assessment with the child or young person prior to the initial case conference to identify any health needs. If the notification to school nursing services is delayed and this cannot be done, the health assessments must be carried out no later than the first key stage. This is referred to by professionals as the "first core group" meeting.

This health assessment will inform the report submitted into the conference. It will be child centred and involve directly with the child or young person in advance. The report will include the child or young person’s feelings, desired outcomes, wishes and what matters to them, including any unmet health needs. A professional decision informed by the health assessment will then be made through the case conference as to whether any continued involvement is necessary at any subsequent reviews or core groups. Involvement will recommence if new concerns emerge.

The health assessment is vital in identifying potential health concerns and issues, ensuring timely interventions are planned and promoting prevention. It provides opportunity for health education in relation to core themes including:

• nutrition
• continence
• immunisations
• dental
• support for both the child / young person and their family

All school aged children regardless of educational setting will have the most appropriate health professional involved. For example:

• paediatrician
• nurse in special school
• general practitioner (GP)
• allied health professional
• community children’s nurse
• specialist community public health nurse (school nursing)
• a child and adolescent mental health service professional

The lead health professional role coordinating and attending all case conferences on behalf of NHS Wales must not default to school nursing services. The lead health professional attending the conference must have a meaningful and significant contribution to make around the family and child / young person. It is extremely important the lead health professional at the safeguarding conference knows the child or young person and family where appropriate, to deliver the best safeguarding outcomes for the child or young person.

Relationship and sexuality education is crucial for all children and young people for several reasons. Provided with accurate information, children and young people are empowered to make informed, healthy, respectful and responsible choices about their sexual health, relationships and wellbeing.

The education sessions are delivered by school nursing services and they provide information on the following areas:

• healthy relationships
• what to expect during puberty including the physical and emotional changes
• contraception to prevent unintended sexually transmitted infections (STIs) and pregnancies
• the meaning of consent
• respecting diversity
• communicating and encouraging young people to reach out for help
• gender equality

The relationship and sexuality education code 2021 supports schools to design an individually tailored programme to their pupils which is dependent on need. All children and young people will have the opportunity to develop their understanding of relationships and sexuality, taking a rights-based approach in line with the United Nations Convention on the Rights of the Child.

School nursing services will work with individual schools and form part of the wider programme being delivered in the school. The information delivered will be tailored to individual needs and will be delivered using different methods, for example classroom, groups, jointly with families or digital resources.

The content delivered is age appropriate in accordance with the code and is tailored to the age of the child and audience. As children and young people progress through education and mature, the level of detail and information will increase according to the code. The information fosters an environment that encourages an openness, is non-judgemental and is inclusive. Language used is easily understood and relatable to the age group.

School nursing services will deliver information to all children and young people through the universal programme, as set out in the operating model:

• years 5 and 6: growing up, including puberty and hygiene
• year 9: relationships, including sexually transmitted infections
• year 9: relationships, including contraception

During secondary school age, the importance of communication, empathy, and mutual respect in building healthy relationships is provided through school settings. Information is also shared about local services available to young people and how they can access these services should they need to.

In addition to this information, young people can also access the free confidential advice service about sexual health and relationships, provided by school nursing services. The drop-in sessions are an opportunity to discuss a particular topic in more detail with a trained member of staff or to seek more information.