This London Trust’s School Health Service (SHS) serves a total of nearly 100 primary, secondary and special schools across the borough. The SHS employs a total of 17 WTE nurses. Following an analysis of the service, it was revealed that the service provided to each school and by each nurse varied widely – there was no formal expectation of what needed to be delivered and when. The service was also approaching the end of its contract and there was a desire to strengthen the negotiation position for contract extension.
Meridian carried out an analysis at our own cost. During this time, our specialists carried out observations, diary studies, reporting method review and diagnostic interviews with the service managers.
The initial findings from the observations were that each worked autonomously and that this was not governed by specific targets or KPIs. The nurses were dealt mainly with safeguarding and care planning meetings, with the majority attending lengthy case conferences. Out of the observed nurses’ time, 32% was spent on school premises and only 10% of the time was spent with a child present. Only 37% of the observed nurses saw a child during their working day. The diary study and reporting review confirmed that a great amount of time was spent participating in the conferences and little time was spent on school premises with children or parents and teachers. From the point of view of the managers the benefits coming from the service were not conveyed through the structure and activities carried out by nurses.
The project focused on completely redesigning the service by reviewing in detail the activities and categorising them into the necessary and unnecessary as well as adding new activities to the service model. The design stage of the process took place in the form of workshops with the heads of service and school nursing representation. Appropriate activities were added to the model (table right) and core service requirements built in to fulfil the needs of the service considered by its heads, to meet the expectations from local authorities and head teachers and to ensure the visibility of a school nurse within their designated schools.
The activities required to be undertaken by nurses in terms of professional development were also taken into consideration and added to the total required time.
The model took into consideration the capacity required to meet the desired service model’s need, expressed in time.
This allowed conversion of the total available nursing time into the appropriate activities in the schools and the current team size to be fully utilised without the need for more resources. The modelling tools designed specifically for the service by the Meridian team enabled the allocation of nurses to appropriate schools based on their grades and skills as well as their capacity and time demand per school.
This modelling is now possible at the Executive level, to assess overall capacity, as well as at the nurse level to assist in assigning the appropriate activities to ensure optimum resource utilisation.
Below shows a process flow picturing the elements of the service management control system:
The service modelling is also supported by an activity monitoring process. All nurses have an assigned Team Leader who allocates detailed work to their team members. The activity is also recorded on the local system and weekly reports are available to show the total time spent per nurse per school on delivering each activity.
The programme was well received by all members of the service. Everyone took part in shaping the new way of working as it benefitted every stakeholder to reshape the service. Each service user received a handy manual regarding service delivery – the nurses hold detailed booklets listing all the activities and guiding them through the delivery of each of them. Head teachers were also equipped with service model manuals detailing what activities will be delivered to their pupils.
The effects of the implementation were complimented by the service users as extremely positive. The effects of the implementation were readily complimented by the service users. Head teachers’ feedback to the Head of the Service was extremely positive regarding seeing their nurse every week.
- Nurses spend 87% of their working time on school premises (an increase 55% face-to-face time compared to pre-project);
- Each nurse visits their assigned schools at least once per week;
- A nurse is available and on premises for an average of one full day per week per school;
- Special schools receive continuity through dedicated nurses;
- Head teachers involved in the shaping of health promotion and drop-in sessions in schools;
- Higher visibility of the service within the borough;
- Each head teacher is equipped with a service model booklet for reference purposes;
- Each nurse owns a booklet which details the activities required including the time to perform, frequency and a method of recording work carried out.