MEMORANDUM TO THE BOARD
26 MARCH 2014
AGENDA ITEM 6.8
SECONDARY SCHOOL BASED HEALTH SERVICES REVIEW
Purpose
In 2013 a review of health services provided in Waikato secondary schools was
undertaken to determine how best to use the current funding (which includes both
new money from the Ministry of Health for School Based Health Services and long
standing Waikato District Heath Board funding for general practices in schools) to
improve access to primary care for students. The review has also looked at
addressing inequalities and gaps in current service provision, which effectively
means a resource reallocation from higher decile secondary schools to lower decile
secondary schools.
The review ascertained the need to maintain the current level of funding for these
services, but suggests way that this funding might be better targeted. That would
entail increases in some areas and reductions in others. There is more work to be
done with Midlands Health Network to determine how best to implement the
recommendations and what level of service can be available for secondary schools
which are above Decile 3 if the recommendations are adopted.
Background
The review was led, and will be presented by Dr Linda Rademaker who had a
previous position in Waikato District Health Board as the General Practice Liaison
and subsequently worked at Midlands Health Network as Medical Director. The
review recommendations were developed after lengthy consultation with all health
professionals and senior managers involved in the services. Youth were also
consulted as were school principals.
Provision of primary care services in secondary schools assists Waikato District
Health Board to meet service coverage requirements for youth as the Ministry
expects that school based health services will be an integral part of youth health
plans. The recommendations from the review also mean we are more likely to be
able to deliver on a number of components of the Prime Minister’s Youth Mental
Health Project, such as expanding school based health care to selected secondary
schools, which is one of our Ministry of Health reporting measures.
The 2013/14 funding was $484,623 for general practice in schools and $620,893 for
school based health services, a total of $1,105, 516. The Midlands Health Network
receives this funding and provides most of the service directly, subcontracts to Health
Waikato Community Health Services for provision to two secondary schools.
This expenditure is in addition to routine public health nurse visits, which are
provided by Health Waikato to all secondary schools, and adolescent health clinics
which are provided in selected schools. Midlands Health Network has advised the
reviewer that a scoping exercise is underway which has provisionally indicated that
additional funding would be required to implement the recommendations. Developed
discussions regarding implementation considerations such as that have not yet
however been held.
Presentation
Dr Rademaker will present to the Board with assistance from relevant Planning &
Funding personnel.
Recommendation
THAT
1) The Board receives this presentation and notes further analytical work to
agree level of services to secondary schools needs to be done in
collaboration with Midlands Health Network and Health Waikato Community
Health Services;
2) The Board agrees all current funding is maintained for the 2014/15 year to
support the implementation of the recommendations.
BRETT PARADINE
GENERAL MANAGER, PLANNING & FUNDING
2013
Secondary School Based
Health Service Review
Linda Rademaker
Waikato DHB
Contents
Executive Summary ................................................................................................ 1
Recommendations ................................................................................................ 4
Introduction ............................................................................................................. 4
Background ............................................................................................................. 5
Current situation ..................................................................................................... 8
1. Agreements ....................................................................................................... 8
2. Current Services ................................................................................................ 8
3. Service Provider Roles ...................................................................................... 8
4. Services in other DHBs ................................................................................... 10
The Problem .......................................................................................................... 11
1. Service gaps and anomalies............................................................................ 11
2. Opportunities for collaboration and coordination .............................................. 12
3. Information gaps .............................................................................................. 12
4. Operational support ......................................................................................... 12
Evidence and Best Practice.................................................................................. 13
Methodology .......................................................................................................... 14
1. Consultation .................................................................................................... 14
2. Principles to guide future state ........................................................................ 15
3. Constraints ...................................................................................................... 15
Model ..................................................................................................................... 16
Deciles 1-3 and TPU proposed model ................................................................. 16
Alternative Education........................................................................................... 17
Deciles 4-6 .......................................................................................................... 19
Deciles 7-10 ........................................................................................................ 20
Prioritisation of proposed services within available funding ................................. 20
Recommendation ................................................................................................ 21
Monitoring and Evaluation ................................................................................... 22
Recommendation ................................................................................................ 23
Governance/leadership ......................................................................................... 23
Recommendation ................................................................................................ 23
Professional development and support .............................................................. 24
Recommendation ................................................................................................ 24
Pathways and decision support tools ................................................................. 24
Recommendation ................................................................................................ 25
Risk assessment ................................................................................................... 25
Transition pathways/timetable ............................................................................. 26
References ............................................................................................................. 27
Appendix 2 ............................................................................................................. 30
Gap analysis ....................................................................................................... 30
Appendix 3 ............................................................................................................. 31
Reference Group Members ................................................................................. 31
Appendix 4 ............................................................................................................. 32
Common themes from stakeholder feedback ...................................................... 32
Appendix 5 ............................................................................................................. 33
Monitoring Framework ......................................................................................... 33
Appendix 6 ............................................................................................................. 37
Project Board ...................................................................................................... 37
Glossary................................................................................................................. 38
Executive Summary
Since the first general practitioner and nursing services were introduced to Waikato
secondary schools, there has been gradual growth and development supported by
national and local contractual arrangements. Early development was ad hoc and,
while there has been coordination of services managed by individual providers,
coordination between provider organisations has not been formalised.
This review will recommend how services should be configured and coordinated for
the future to provide the most effective service within current funding parameters,
especially for those most at need.
Services to be reviewed are provided through three service agreements:

School and Preschool Health Services Tier 2. A national contract that funds
Public Health Nurse (PHN) self-referral clinics (SRC) in secondary schools
managed by Waikato District Health Board (WAIKATO DHB) Rural and
Community Service

School Based Health Services (SBHS) – General Practice in Schools.
Funded by WAIKATO DHB and managed by Midlands Health Network (MHN)
to provided general practitioners (GP) in decile 5 and below schools and
registered nurses (RN) in decile 4 and 5 schools

School & Preschool Health Services Tier 3. A national contract that funds
RNs in deciles 1-3 schools, alternative education (Alt Ed) and teen parent
units (TPU), managed by MHN
An analysis of current service provision has demonstrated gaps, anomalies and
inequities in service provision, opportunities for collaboration and coordination
between providers, the need for more robust evaluation and gaps in operational and
professional support for school based health service clinicians who frequently work in
relative isolation.
A literature review has identified only a small amount of supporting evidence for
improved health outcomes as a result of school based health services, although
there is substantial belief that the service is beneficial. Feedback from schools,
students and those providing the service strongly supports the service as providing
health care to students who would otherwise not access health care because of cost,
1
transport, carer inertia and confidentiality issues.
Equipped with information about current services and available evidence, a reference
group of key stakeholders has developed a proposed future model, utilising the
expertise, knowledge and experience of individual members.
The model assumes no reduction in funding and no political change.
It is agreed by the service providers that the role of MHN employed RNs and
WAIKATO DHB employed PHNs in self-referral clinics is – or should be - identical. In
the proposed model the RN role could be provided by either, depending on the local
environment. The service provided should be collaborative, coordinated, uniform, use
the same referral guidelines, pathways, procedures and a shared record system. A
common professional development pathway should be adopted. While school
employed nurses and private school arrangements with GPs are not part of this
review, these professional groups should also be invited to participate in all
collaborative professional and service development opportunities. Actions in relation
to nursing roles will interface with the proposed Community Nursing Project.
In order to deliver the level of service determined by the School and Preschool
Health Services Tier 3 service specification, within the available funding envelope,
and to address the identified service gaps and anomalies, some re-prioritisation will
be necessary. While acknowledging the deficiencies of the decile system, to address
inequalities the proposed model recommends a cascade of services with highest
priority given to Kura Kaupapa Maori, deciles1-3, Alt Ed and TPUs. Next priority is
deciles 4-6 schools and lowest priority deciles 7-10 schools.
Intended baseline services are;

Deciles 1-3, Alt Ed, TPUs. RN service in all schools in line with ratios defined
in the School & Preschool Health Services Tier 3 service specifications plus
GP on site for a minimum of 2hrs per week, with the exception of Alt Ed
where GP services may need to be provided off site because of the small
numbers of students. Where recruitment is difficult a GP telephone advice
alternative could be considered

Deciles 4-6. Minimum of a RN service to all schools plus a GP service,
preferably on site for a minimum of 2hrs per week, or alternatively advisory by
telephone or by access arrangement with a local practice

Deciles 7-10. PHN usual Tier 2 service with the possibility of more frequent
visits based on need plus, possibly, a GP advisory service, if affordable,
2
where there is identified need
Order of priority for funding will be;
1. Fill RN gaps in decile 1-3 schools, TPU and Alt Ed
2. GP presence in all deciles 1-3 schools
3. Deciles 4-6 services as above. If funding has to be further prioritised within
this group priority should be RN plus GP for decile 4, RN plus GP decile 5,
RN plus GP decile 6, GP only service, then RN with GP advisory. In addition,
ethnicity as a marker of need should be considered if funding is not available
to provide a service to all decile 4-6 schools
4. GP advisory in decile 7 - 10 schools
It will be clear what level of service prioritisation can be met once a scoping exercise
is completed by MHN and WAIKATO DHB Rural and Community Services to match
prioritisation to available funding.
Robust evaluation is the only means of knowing whether the service is effective,
efficient and beneficial to the school community. A framework for evaluation is
recommended. An extract from an electronic system is the best practical way of
achieving reliable information without compromising clinical contact time, but does
require activation of MedTech, BPAC and the e-referral tools in all school clinics, and
to all provider groups, including PHNs. Further work is required to understand how
much information can currently be extracted electronically, what will be feasible, by
when and at what cost.
Arrangements for governance and clinical leadership are proposed, and an
integrated professional development and support framework will be developed.
The need for clear referral pathways to other primary and secondary health services
is recognised. However this should be part of the significant broader work on
development of referral pathways and decision support tools in primary care. To
develop pathways for SBHS in isolation would risk lack of integration and
unnecessary duplication and cost.
MHN and WAIKATO DHB Rural and Community Services will complete scoping of
the proposed model for deciles 1-3, Alt Ed and TPU by 31 January 2014. MHN will
3
scope the model for deciles 4 upwards and develop an implementation plan, both to
be submitted by 28 February 2014 aiming for Implementation by 1 July 2014.
Recommendations
1. The proposed model is endorsed and adopted from 1 July 2014
2. The proposed monitoring template is applied and reported against across all
SBHS from 1 July 2014
3. A specific governance group for SBHS, led by MHN but including all
significant parties (including school employed nurses and principals) and
sitting under the Waikato Alliance Leadership Team framework should be
established by 1 July 2014
4. A model to provide clinical leadership for all SBHS clinicians, where it does
not already exist, will be identified by 1 July 2014
5. An integrated professional development and support framework should be in
place for all SBHS GPs and Nurses by 1 July 2014
6. In the context of the broader development work on pathways and decision
support tools, that relating specifically to SBHS should be addressed jointly
by MHN and WAIKATO DHB Rural and Community Services and be
identified in the Implementation Plan by 28/02/2013
7. If the scoping exercise, or development of the implementation plan, identifies
any reason that variation in the above recommendations is necessary, this
should be referred to the Waikato Alliance Leadership Team for approval.
Introduction
General Practitioner clinics were first established in Waikato secondary schools in
2003 and the first nurse led clinic in 2009. Initial development SBHS was largely
driven by local enthusiasm and relationships. As a result early development was ad
hoc.
More formal contractual arrangements at both a national and DHB level have
supported the expansion of the service, although not necessarily overall
coordination. A report to the Ministry of Health in 2009 identified that absence of
policy and ad hoc development might contribute to discrepancies in availability and
access to services.1
4
This review will consider how services are currently operating, whether that best
meets the needs of the student users, especially those most at need, and
recommend how services should be configured and coordinated to provide the most
effective service within current funding parameters.
Background
The Project Initiation Document summarises the background, objectives and scope
of the review. Essentially the purpose is:

To ensure current services are integrated to provide a coherent service,
prioritised to those who need it most

To recommend the best option for the future state of school based primary
health care services for Waikato secondary schools within current funding
levels

To describe clear referral pathways to other primary and secondary health
services (both to those delivered in schools and those delivered in other
settings)

To recommend a staged transition from current state to future state

To ensure key stakeholders are involved at all stages of the review
In scope are primary healthcare services provided in Waikato secondary schools by
Public Health Nurses (PHN), Registered Nurses (RN) and General Practitioners (GP)
funded through the following three service agreements:
1. School and Preschool Health Services Tier 2

National specification

PHN delivered, mainly in primary and intermediate schools

Secondary school service includes a regular visiting programme with a
minimum of two visits per term, although flexibility is applied by the PHN team
to respond to identified local need
2. School Based Health Services – General Practice in Schools

Waikato District Health Board (WAIKATO DHB)/Midland Health Network
(MHN) service agreement

GPs and/or RNs provide free primary health services in school clinics on a
routine, usually weekly, basis

Delivered to deciles 5 & below schools, although some flexibility has been
applied responsive to local need
5

Complimentary to other health services provided in schools

Key objective is access to high needs students
3. School & Preschool Health Services Tier 3 (revised and extended September
2013)

National Specification

Delivered mostly via MHN, small contract with Raukura Hauora for
Raukaumanga

Requires RN in all deciles 3 & below, Alternative Education (Alt Ed) and Teen
Parent Units (TPU)

HEEADSSS to be provided to all year 9 in deciles 1-3, all students in Alt Ed
and TPU

Requirement for follow up of referrals

Requirement to ensure all users know who their GP is, where to go outside
facility hours and get assistance with PHO enrolment

Specifies 1 FTE RN to 750 students in deciles 1-3 and 1 FTE RN to 200
students in AE and TPU

Specifies 1 nurse leader: 10 RNs
Apart from some RNs directly employed by schools using education funding, and
private visiting arrangements between some higher decile schools and local GPs, no
other funding streams have been identified for the services in scope of this review.
Out of scope:

Mental Health & Addictions Services

Health Promotion

Sexual Health Services

Community Oral Health Services
There are a number of other initiatives and service development activities both at a
national and local level that relate to SBHS. It is important to acknowledge those that
will interface with this review. Those identified include:

Prime Minister’s Youth Mental Health Project. Specifically included in this is
the expansion of funded RN services and HEEADSSS to include decile 3
schools

Community Nursing Project due to commence Feb 2013. This is part of the
Waikato Alliance Leadership Team (WALT) work with MHN

MHN internal review of SBHS 2012. An operational review that identified a
6
number of issues that have been, or are being, addressed by MHN. These
included IT instability (resolved), clinical support (in progress), auditing
process (resolved), student perspectives (resolved), policies, standing orders
and procedures development (in progress)

MHN service provider forums focusing on operational issues. Key themes
raised are practicing environment, clinical resources, technology,
relationships, and professional support

Social Sector Trials. Inter-sectoral programmes for 12-18 yr olds with the aim
of reducing crime and alcohol use, increasing school attendance and
improving transition into employment that are currently underway in Tokoroa,
Te Kuiti, Taumarunui and Waikato Territorial Local Authority Area

Alcohol & Drug service exemplar. An initiative aiming to improve coordination
of existing services

Map of Medicine. Some of the initial focus is on depression and alcohol and
drug abuse, together with other common primary care presentations.

Vulnerable Children and Child Action Plan related projects

Gateways. This relates to young people in Child Youth and Family care

National Child Health Information Platform. The current focus is on the 0-6
age group

MHN Child & Youth Health SLAT recommendations include targeted yr 9
HEEADSSS and using every health intervention to ensure school aged
children are enrolled and engage with their GP team

Rheumatic Fever prevention initiative
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Current situation
1. Agreements

School and Preschool Health Services Tier 2

School Based Health Services – General Practice in Schools

School & Preschool Health Services Tier 3 (revised and extended September
2013)
No alteration to these contracts or reduction in funding is anticipated. However, to
reflect the outcomes of this review, provider specific terms and conditions may be
agreed with relevant providers.
2. Current Services
Under the contracts above, personal primary care school based health services are
provided by PHNs, RNs and GPs. In addition, some schools employ their own nurses
from school funds. Occasionally, RNs are partly employed directly by the school and
partly by MHN for their work in an individual school. In one case (Paeroa) a PHN is
sub contracted to fulfil the SBHS RN role via MHN.
Appendix 1 has a complete overview of provision across the Waikato.
Appendix 2 identifies the FTE gap by decile and for Alt Ed and TPU facilities if the
ratios required in the School & Preschool Health Services Tier 3 service specification
was to be applied across all schools.
3. Service Provider Roles
Public Health Nurses
The PHN role is funded through the School & Preschool Health Services Tier 2
service specification.
There is a PHN allocated to every Waikato secondary school but the level of services
8
delivered within each school depends on criteria developed by WAIKATO DHB Rural
& Community Services based on the decile of the school and identified local need. In
relation to the scope of this review the service has three main focuses:

Referral based service for personal health care. Referrals can be self, or from
parents, teachers or other health providers via the Rural and Community
Regional Referral Centre

Support to schools for specific student health issues

Self-referral clinics, all but one of which are in rural schools
Medical support is via a contracted GP who is available for telephone advice.
PHNs do not use any standing orders in SBHS clinics but do have a number of
supporting referral and clinical pathways.
The PHN scope differs from other SBHS nurses in offering home visiting,
communicable disease follow-up and providing continuity of care in the transition
from primary school, together with, possibly, a more broad public health focus.
There is no prerequisite qualification for a PHN. The service provides orientation, inservice training and ongoing professional development.
SBHS Registered Nurse role
RNs provide primary healthcare in SBHS clinics funded through the following service
agreements:
•
School & Preschool Health Services Tier 3 - MHN employed or contracted
from PHN service in decile 1-3 schools, TPUs and Alt Ed
•
Raukura Hauora contract with WAIKATO DHB for an RN in a single decile 1
school
•
School Based Health Services – General Practice in Schools - MHN
employed in deciles 4 and above
There is one Nurse Practitioner (NP) in the Fraser High School TPU.
MHN provides specific in-service training for school-based nurses.
SBHS GPs
SBHS GPs are funded through the School Based Health Services – General Practice
in Schools service agreement and employed by MHN.
There is the view that GPs add value by providing support for the RNs, contributing
to a coordinated approach, extending the scope of the service and probably reducing
referrals to secondary providers.
9
School employed nurses
School funded and employed but fulfilling a similar role to PHNs in self-referral clinics
(PHN SRC) and MHN employed RNs. Funding for these roles is from the school
operational budget and is an individual school prioritisation decision. They are invited
to participate in professional development by both the PHN service and MHN.
Information about service volume is not available to this review.
Private GP arrangements
Some higher decile schools have private arrangements with local GPs for visiting
services. Information about service volume is not available to this review.
4. Services in other DHBs
In 2009 75% of New Zealand secondary schools had a nurse in attendance or
visiting, but only 2% were employed by a primary health organisation (PHO). Most
were undertaking less than 20 consultations per week.1
All DHBs are now required to provide an RN SBHS as outlined in School &
Preschool Health Services Tier 3 service specifications.
Some information about the configuration of services in the other Midland DHBs has
been received. In Lakes DHB there are GP clinics in most secondary schools, funded
through a mix of DHB, primary care and GMS funding.
All services are delivered through two youth health services that cover the whole of
the DHB area, with contracts to provide Youth One Stop Shops, one in Rotorua
(Rotovegas) and the other in Taupo (CAFÉ).
In Taranaki there are GP clinics in two secondary schools (neither is decile 1-3) with
a specific sexual health focus. Nurse services are via PHNs, with GP advice as
necessary.
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The Problem
1. Service gaps and anomalies
An overview of current service provision and gaps (appendices 1 and 2) identifies
issues with service distribution. Services are not necessarily prioritised based on
need. Some high decile schools have service and some low decile schools do not.
RN service
•
Decile 1-3 schools service specification requires a nurse to student ratio of
1:750. Some schools have more, some have about the required ratio, some
less and some (Pa Harekeke TPU, Te Wharekura o Te Kaokaoroa o
Patetere, Te Wharekura o Te Rau Aroha, Coromandel) have no current
service
•
Decile 4-6 schools have a mix of nursing services across the 18 schools. Of
the 10 decile 4 schools, 1 has an MHN nurse and 2 have a PHN self-referral
clinic. The only decile 5 school that has no service. Of the 7 decile 6 schools,
6 have a PHN self-referral clinic and 1 has no service
•
To provide the required nurse to student ratio in decile 1-3 schools 5.81 FTE
RNs are needed. 4.19 FTE is currently in place giving a gap of 1.62 FTE
•
Based on the required ratio of 1 RN: 200 Students for TPU 0.265 FTE is
required. Current FTE is 0.2 giving a gap of 0.065 FTE
•
Based on the required ratio of 1 RN: 200 Students for Alt Ed 0.97 FTE is
required. Current FTE is 0.4 giving a gap of 0.57 FTE
GPs
•
Of 19 decile 1-3 schools, 10 are without a GP although 5 are currently being
scoped for service by MHN with the intention of GP appointment to those
schools
•
Of 18 decile 4-6 schools, 12 have a GP service (Thames is provided via the
local GP practice). Of the remaining 6 schools, 1 has recruited, 1 is currently
recruiting, 1 school has only 1 secondary aged student, 1 has a local
standing order arrangement with the local GP and 2 are vacant
•
Of 11 decile 7-10 schools, 3 have a funded GP service
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MHN has already identified these issues and started to re-focus the service they
provide by focusing on deciles 1-3 and reducing input to high decile schools or
schools where there is little demand e.g. Sacred Heart, Hamilton Boys High School
and St Johns
2. Opportunities for collaboration and coordination
Opportunities for collaboration are easily identified e.g. the potential for expansion of
the collaborative model established in Paeroa between MHN and the PHN service,
and the sharing and shared development of pathways, procedure manuals etc
between the different service providers.
It is agreed by the service providers that the role of MHN employed RNs and PHNs
in self-referral clinics is identical. Students make no distinction between MHN RNs
and PHNs or the school nurse and expect the same service. The service provided
therefore should be collaborative, coordinated, uniform, use the same referral
guidelines, pathways, procedures and a shared record system. A common
professional development pathway should be adopted.
3. Information gaps
While some process related information is reported and available from individual
providers, it is not routinely amalgamated to provide a review of the entire service in
a cohesive fashion.
Good information about utilisation in relation to equity and disparity is not easily
available.
Evaluation of outcomes is very basic and there is a lack of robust information that
could establish the impact of SBHS on health outcomes.
4. Operational support
MHN has identified the need for further development in a number of areas to support
the GPs and RNs in SBHS who often work in relative isolation. Practicing
environment, clinical resources, technology, relationships and professional support
are all areas tagged for attention as part of an MHN action plan for SBHS.
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Evidence and Best Practice
While a literature search has produced much published information on school based
disease or service-specific interventions, only a small amount of supporting evidence
has been found for health outcomes as a result of SBHS.
A sense that it must be beneficial pervades the available literature mostly based on
subjective rather than objective information or substantive outcome measures.
A UK based systematic review of school linked sexual health services concluded that
the evidence base for these services is limited and uneven, drawing mainly on US
studies, and that further qualitative research is needed.2
A recent systematic review of the role of school based health care on adolescent
sexual, reproductive and mental health identified a paucity of high quality research.
There was, however, evidence that a SBHS is popular with young people, provides
important services and may have cost benefit by reducing disparity and secondary
care attendance.3
Secondary students do use SBHS in relatively reasonable numbers. A recent NZ
overview reported that 18% of secondary school students who accessed primary
health care did so through their SBHS, as opposed to 74% via their GP.4
There is some indication also that positive outcomes in relation to reduced
pregnancy and use of contraception are dependent on a multidisciplinary approach5
and a minimum number of clinic opening hours.6
The employment status of the SBHS nurse may be important. School employed
nurses more likely to deal with first aid and less with personal health services,
assessments and medication than DHB/PHN employed.1
A review of available literature for a MOH report in 2009 identified that an “effective
SBHS need to have wide engagement with their school and community, a youth
focus and participation, delivery of high quality care and effective
administrative/clinical systems and governance to support service delivery”.1
In relation to prioritisation of services, the decile rating is often a factor utilised in
determining what services will be provided to a particular school, although other
13
factors such as rural isolation, a significant transient population, or the needs of
specific ethnic groups are important. Referral rates (highest in deciles 4-6, but almost
as high for deciles 7-10 as for deciles1-3) support a view that there is need within
schools of all deciles.1
The awaited MOH document, Youth Healthcare in Secondary Schools: A framework
for continuous quality improvement is expected to be helpful.
Methodology
1. Consultation
A reference group of key stakeholders was established. Equipped with information
about current services and available evidence this group developed the proposed
future model, utilising the expertise, knowledge and experience of individual
members.
In addition to the Reference Group, a consultation process took place with a number
of other stakeholders:

School Principals. Because of other commitments in the school calendar at
the time of the review, it was not possible to identify a school principal to
participate in the reference group. A broader approach was taken, with the
Clinical Lead visiting a representative selection of schools and interviewing
principals, or delegated members of the school management teams. Where
possible these visits also included time with school clinic staff, including
managers and nurses (including school employed nurses)

Students. The opinions of students have been canvassed through a number
of student focus groups convened by South Waikato Pacific Islands
Community Services, Te Ahurei a Rangatahi Trust and Midlands Health
Network (MHN)

Raukura Hauora. Karina Elkington, WAIKATO DHB Planning and Funding
portfolio manager will advise them of the review. They have a small contract
for 0.2 FTE RN at Raukaumanga. Given the school roll and that they are
decile 1, it is not anticipated that this review will adversely affect the service
14

School GPs. The Clinical Lead met with the School GP peer group to discuss
the review and listen to feed back
Key themes from the consultation process are identified in appendix 4.
The Reference Group did not identify any other key stakeholders.
2. Principles to guide future state
Reference Group members identified the following principles as the basis for
developing a model for future SBHS in Waikato secondary schools:

A free student focused service that is safe and confidential

Best use of available resources to effect a practical, do-able and affordable
service

A consistent, quality-focused, multidisciplinary approach, ensuring the service
is delivered by the right person with the right tools in the right setting

Equitable access that addresses disparity, particularly in relation to Maori and
Pacific students and our rural community

Integrated and coordinated care utilising service links and referral pathways
with a focus on clear connections to general practice teams and non-school
hours services

Measurable outcomes including measures of reducing disparity, health
outcomes, enrolment with a primary care provider and social outcomes such
as retention in mainstream education
These principles align with those identified by the Department of Health in the UK to
help develop “young people friendly” health services.7
3. Constraints
School and Preschool Health Services Tier 2 and Tier 3 are national service
specifications and therefore the parameters and requirements of these specifications
are unchangeable.
While there is no proposal to reduce funding, no increase in funding is anticipated.
15
Model
In order to deliver to the level of service determined by the September 2013 School
and Preschool Health Services Tier 3 service specification, within the available
funding envelope, and to address the identified service gaps and anomalies, some
re-prioritisation will be necessary.
Public Health Clinician advice is that to address inequalities, highest priority should
be Kura Kaupapa Maori, deciles1-3 (and schools with high Maori/Pacific enrolment
which are likely to be the same group), Alt Ed and TPU, next priority deciles 4-6 and
lowest priority deciles 7-10 (bearing in mind the difficulties with the decile system).
There may be a need to consider deciles 7-10 through a more “universal” system.
In addition the identified service gaps and anomalies will be addressed.
Services will be re-focused into 3 bands;
1. Deciles 1-3, TPU, (Kura Kaupapa Maori are all deciles 1-3 in Waikato),
Alternative Education
2. Deciles 4-6
3. Deciles 7-10
Deciles 1-3 and TPU proposed model
(Alternative Education poses some specific challenges and will be addressed
separately).
Considerations
Basic requirement of national service specifications:

RN 1:750 – or 1:200 for TPU

HEEADSSS for all year 9 students and students in TPU

Follow-up of referrals

Ensure all users know who their GP is and where to go outside facility hours,
assistance with PHO enrolment
RN role

Can be MHN/PHO employed or PHN SRC

Affordable solutions are available
16

Agreed that the service provided by MHN employed RNs and PHNs in self
referral clinics should be uniform, using the same referral guidelines,
pathways and a shared record system
GP role adds value by

Collaborative working relationships with RNs

Benefits of having GP and RN in schools at the same time

Providing medication on PSO

Strengthening link and contacts with student’s enrolled GP team

Utilising pre triage by RNs to maximise impact of GP service

Ensuring appropriate referrals to other services
Proposal
1. Fill RN gaps with either MHN RN or PHN SRC depending on locality need
and resource available. For decile 1-3 schools, based on 1 RN: 750 students,
5.81 FTE is required. Current FTE is 4.1875, leaving a gap of 1.62 FTE. It is
anticipated that this gap will be funded within current budget from the School
& Preschool Health Services Tier 3 service agreement. For TPU based on 1
RN: 200 students, 0.265 FTE is required. Current provision is 0.2 FTE
leaving a gap of 0.065 FTE
2. GP presence in all decile 1-3 schools for minimum of 2 hrs/week

Currently 4 schools either without, or with no scoping or plan to recruit in
place. (1 is Raukura Hauora contracted)

Ideally GP clinic in school, alternative is GP advice available by telephone

Minimum practical GP FTE/school is 0.05=2hrs/week

Funding from School Based Health Services – General Practice in
Schools service agreement by transition from funding deciles 7-10 to
deciles1-6 and re-scoping financial budget
Alternative Education
Considerations
MOH requirements:

RN service to all in Alternative Education (Alt Ed)

HEEADSSS for all students in Alt Ed

Follow-up of referrals

Ensure all users know who their GP is and where to go outside facility hours,
17
assistance with PHO enrolment.

1 FTE RN to 200 students in Alt Ed i.e. 0.97 FTE for Waikato
Enrolments:

194 funded Alt Ed places across Waikato per year

Enrolled at 17 different sites

Funded places/site vary from 2–53 (< 10 at 9 sites, 11-20 at 7 sites and
Melville High School consortium has 54 places.)
While Alt Ed students are all enrolled at an identified school and that school has a
pastoral care responsibility for the students, they are usually not physically at that
site.
They may be at other schools or facilities, and may access SBHS at any facility they
attend.
Enrolments vary through the year but there are a maximum number of funded
places.
Some students may be at sites without a SBHS or not attending a school site.
Some schools do not want Alt Ed students on site because of previous dangerous
behaviours.
Proposal
1. Required FTE to meet 1 RN: 200 student ratio is 0.97. Current FTE is 0.4,
leaving a gap of 0.57 FTE. It is anticipated that this gap will be funded within
current budget from the School & Preschool Health Services Tier 3 service
agreement.
2. Parental permission for the HEEADSSS assessment should be sought
through the same opt off system as for year 9 students in mainstream
schools.
3. Actual service provision model will be responsive to the local environment.
Ideally a RN would provide it on site at the Alt Ed facility, such as in the
current Paeroa model. Where this is not possible or appropriate facilities
cannot be provided at the Alt Ed site (e.g. for vision and hearing testing), then
the student would be taken to the nearest school clinic. Occasionally it may
be necessary to refer to the PHN service if home visiting is required.
GP services for Alt Ed will have to be worked out on a site by site basis
because of factors such as the small numbers at most sites and differing
approaches by principals to having excluded students on site. Options would
be referral as needed by the RN to either the "parent" school GP, a local
18
practice by arrangement or the local school GP visiting to see students
referred by the Alt Ed RN as needed.
Deciles 4-6
Considerations
Environment:

Mostly Rural

Significant differences between rural and urban in access to other
services

In rural, general practice services at usual cost, emergency contraceptive
pill (ECP) free, transport issues. In urban, family planning and sexual
health services free, ECP free, general practice services at usual cost.
Transport issues less
RN role
Desirable to offer a minimum of PHN SRC, frequency and FTE responsive to needs
assessment. While a small number of deciles 4-6 schools have prioritised funds from
their operational budget for a school nurse, they should be offered the same health
funded RN input.
GP
Either GP on site or available for telephone advice (some currently have both on site
GP and advisory)
Proposal
1. RN service to all schools:

Currently 3 rural schools have no service. Consideration to be given to
PHN SRC for those schools

Currently 3 urban schools with no nurse. Consideration to be given to
service via MHN employed RN for those sites
2. GP service to all schools:

Currently only 2 schools with no arrangement in place or a plan to provide
a service underway

Ideally a minimum 0.05 FTE (2hrs) per week

May consider GP advisory as an alternative to GP on site or an access
arrangement with a local practice such as that operating in Thames at
present, if need to prioritise funding further
3. Existing funding from School Based Health Services – General Practice in
19
Schools service agreement managed by MHN and School and Preschool
Health Services Tier 2 service agreement managed by WAIKATO DHB Rural
and Community Services.
4. If funding constraints enforce a decision on which holds more importance,
GPs in schools or filling RN roles, then apply flexibility around individual
school needs. A case could be made for a GP presence in decile 4 schools
whereas in deciles 5-6 schools an on-site RN with supporting access to GP
telephone advice may be sufficient.
Deciles 7-10
Considerations

Mostly urban

PHN Tier 2 service involved

Many have school employed RN/GP

Currently no MHN RN or PHN SRC in any decile 7-10 school

MHN employed GP in 3 decile 7-10 schools
Proposal
1.
No MOH funded RNs in deciles 7-10 schools.
2.
PHN usual tier 2 service (i.e. not PHN SRC) and the possibility of more
frequent visits based on need.
3.
GP advisory service, if affordable when other priorities have been addressed,
or the potential to facilitate private school-brokered arrangements with local
GPs.
Prioritisation of proposed services within available funding
A scoping exercise will be carried out by MHN and WAIKATO DHB Rural and
Community Services to match prioritisation to available funding. Only after this
exercise has been completed, led by MHN, will it be clear to what level the identified
service prioritisation can be met.
The following is to be the order of prioritisation of services within the funding
envelope:
1. Fill RN gaps in decile 1-3 schools, TPU and Alt Ed
20
2. GP presence in all deciles 1-3 schools - ideally GP physically in the school
clinic. Where recruitment is difficult a GP telephone advice alternative could
be considered.
3. Deciles 4-6. Ideally there should be minimum of RN (either MHN or PHN
SCR) plus a GP (either on site or telephone advisory or by access
arrangement with a local practice, as currently operates in Thames) in all
deciles 4-6 schools. If funding has to be prioritised within this group priority
should be RN plus GP for decile 4, RN plus GP decile 5, RN plus GP decile
6, GP only service, then RN with GP advisory. In addition, ethnicity as a
marker of need should be considered if funding is not available to provide a
service to all decile 4-6 schools.
4. GP advisory in decile 7 - 10 schools.
Recommendation
The proposed model is endorsed and adopted from 1 July 2014.
21
Monitoring and Evaluation
Robust evaluation is the only means of knowing whether the service is effective,
efficient and beneficial to the school community. This is recognised in the School and
Pre-school Health Services Tier 3 service specification, which outlines a number of
reporting requirements in relation to that contract.
However it is also important that compliance with evaluation should not be
unreasonably onerous; in particular, it should not intrude unnecessarily on clinical
contact time.
Allocation of NHI numbers at all students attending SBHS will be essential to create
a cohesive service, particularly in linking SBHS users with general practice teams. In
addition, establishing eligibility for publically funded health services is identified as a
particular challenge in this age group.
Recognised evaluation falls into 3 broad areas:
1. Formative (was the model appropriate, what the process in defining the
model robust and were the right people involved?).
2. Process (measuring what is being provided, who is delivering the service and
who is using it?).
3. Outcome (has the service made a measurable difference to the health of
those who use it?).
Using the Tier 3 requirements as a template against these 3 aspects of evaluation
and applying them across all health funded SBHS provision, a monitoring framework
(appendix 5) is proposed. In addition the views of students on the service should
continue to be sought.
There are some significant challenges to gathering the required information. An
extract from an electronic system is the only practical method of achieving reliable
information without compromising clinical contact time. A significant enabler for the
collection of evaluation data will be activation of MedTech, BPAC and the e-referral
tool in all school clinics. MedTech is currently not available to PHNs and cost of
enabling this is not known.
22
Further work is required to understand how much of the information required can
currently be extracted electronically, what will be feasible and by when. However it
was agreed by the Reference Group that the monitoring and evaluation template is
appropriate as a goal for the service.
Recommendation
The proposed monitoring template is applied and reported against across all SBHS
from 1 July 2014.
Governance/leadership
A review of available literature for a MOH report in 2009 identified that an “effective
SBHS need to have wide engagement with their school and community, a youth
focus and participation, delivery of high quality care and effective
administrative/clinical systems and governance to support service delivery”. 1
The importance of clarity in relation to governance issues has been identified as a
key part of establishing school based health care services. 8
The School and Pre-school Health Services Tier 3 service specification requires 1
FTE nurse leader for every 10 RNs in decile 1-3 SBHS. The Reference Group has
acknowledged the importance of clinical leadership for SBHS clinicians at a practical
level. This is already in place for PHNs working in the service but it is unclear how an
expansion to MHN employed staff will be funded.
Recommendation
A specific governance group for SBHS, led by MHN but including all significant
parties (including school employed nurses and principals) and sitting under the
Waikato Alliance Leadership Team framework should be established by 1 July 2014.
A model to provide clinical leadership for all SBHS clinicians, where it does not
already exist, will be identified by 1 July 2014.
23
Professional development and support
The SBHS require some very specific continuing nurse and medical education. With
a predominantly part-time workforce this can be a challenge to provide both the level
of required services and keep the workforce up skilled. Specific and coordinated
professional development for SBHS GPs and nurses should be established.
There is a need for the development of a common skill set and single set of tools,
including a single electronic database, a suite of clinical policies, procedures and
standing orders, across SBHS, independent of whether the GPs/RNs are MHN or
WAIKATO DHB Rural and Community Services employed. Any identified potential
exceptions will be referred to the governance group for resolution. These should also
be made available to school employed staff. MHN will take a leadership role in
coordinating professional development and support for all SBHSs.
To fully develop a skilled and sustainable workforce, consideration should be given to
a formalised career pathway for SBHS nurses, incorporating undergraduate
experience through to NP roles.
Recommendation
An integrated professional development and support framework should be in place
for all SHBS GPs and Nurses by 1 July 2014.
Pathways and decision support tools
One of the purposes of this review is to describe clear referral pathways to other
primary and secondary health services.
This should be co-ordinated with the broader work on development of referral
pathways and decision support tools in primary care. To develop pathways for SBHS
in isolation would risk lack of integration and unnecessary duplication.
24
Development of decision support tools such as Map of Medicine and BPAC is well
underway. The need to include tools specific to important issues in SHBS such as
smoking cessation, alcohol and drug, mental health, sexual health and contraception
is acknowledged. This will form part of the broader programme of work committed to
by MHN.
Recommendation
In the context of the broader development work in this area, pathways and decision
support tools relating specifically to SBHS should be addressed jointly by MHN and
WAIKATO DHB Rural and Community Services and be identified in the
Implementation Plan by 28/02/2014.
Risk assessment
Risk
Mitigation
Affordability
MHN and WAIKATO DHB Rural and
Community Services to conduct a scoping
exercise to identify affordability within existing
funding.
While no reduction of funding is anticipated,
no increased funding is available so any
changes proposed must be affordable within
current funding.
Prioritisation cascade identified
Political Environment
The recommendations in this report are
based on the premise of no change in policy
and no major political change
Ability to recruit
Some vacancies are due to inability to recruit
suitable applicants. This may be related to
the geographic location of the school and
availability of interested and suitably qualified
individuals in the local community. Feedback
from schools and students has also clearly
identified the importance of the “right person”
– someone who relates to the students and
embarks on a collaborative relationship with
the school.
Collaboration between MHN and WAIKATO
DHB Rural and Community Services to
ensure the best utilisation of current
resources and the best “fit” for the needs of
each locality.
Acceptability to stakeholders
Wide representation on Reference Group.
Services can only be offered to schools. It is
the decision of the School Board of Trustees
whether to accept that offer.
Consultation with wider group of school
principals, school clinic staff and students
25
It is possible that to prioritise services to
where there is most need, it may be
necessary to disinvest in some areas.
Communications
implementation
plan
included
in
Consideration of alternative solutions for any
schools where a service may be adversely
affected and assistance to those school to
find alternatives
Criteria for prioritization
The limitations of the decile system are
recognized. It is acknowledged that even in
the highest decile schools, there can be
pockets of significant deprivation and also
that no matter the socioeconomic status of an
individual student, they may face barriers in
accessing health care
Inability
to
meet
monitoring
evaluation requirements
and
Full compliance with the proposed framework
will not be practicable until all providers have
access to MedTech, BPAC and e-referrals.
There are unknown cost and practical
implications.
Accepted by the Reference Group that the
decile system is the best available indicator
of disparity.
Where
funding
constraints
demand
prioritisation within a decile band, ethnicity
should be used as a further lens.
Reporting should commence using the
proposed framework, recognising limitations
and identifying a phased approach towards
full reporting
Movement in school rolls
Where there is significant movement in
school rolls, the funding model must be
flexible to ensure the service is not
compromised
Transition pathways/timetable
Due Date
Action
31/01/2014
MHN and Rural and Community Services to scope a plan to fill RN gaps in
deciles 1-3 schools, TPU and Alt Ed.
28/02/2014
MHN to scope the remainder of the proposed model.
28/02/2014
Implementation plan completed and submitted to WAIKATO DHB. Planning
and Funding by MHN. To include a communications plan for schools that
may have a significant change in service.
12/03/2014
Paper and presentation for WAIKATO DHB Board to be submitted by Dr
Linda Rademaker
26/03/2013
Presentation to WAIKATO DHB Board by Dr Linda Rademaker and
Planning and Funding team
31/03/2014
Implementation plan approved by WAIKATO DHB Planning and Funding.
1/07/2014
New model in place.
26
References
1. Nursing Services in New Zealand Secondary Schools 2009.
2. Owen J et al School linked sexual health services for young people: a
survey and systematic review concerning current models, effectiveness,
cost effectiveness and research opportunities. Health Technol Assess.
2010 Jun;14(30):1-228.
3. Mason-Jones AJ et al A systematic review of the role of school based
healthcare in adolescent sexual, reproductive and mental health. Syst Rev
2012 Oct 26;1:49.
4. Clark,T.C. et al Youth ’12 Overview: The health and wellbeing of New
Zealand secondary school students in 2012. Auckland, New Zealand: The
University of Auckland.
5. Blank L et al Systematic review and narrative synthesis of the effectiveness
of contraceptive service interventions for young people delivered in
educational settings. J Pediatric Adolesc Gynecol 2010 Dec:23(6):341-51.
6. Denny S et Al: Association between availability and quality of health
services in schools and reproductive health outcomes among students:a
multilevel observational study. Am J Public Health. 2012;102(10):e14-e20.
7. Quality criteria for young people friendly health services 2011. Department
of Health UK.
8. Ministry of Health. 2004. Improving the Health of Young People: Guidelines
for school-based health care. Wellington: Ministry of Health.
27
Appendix 1
Current service provision table
Funding allocation
School Name – as per 2009 Ministry direction
School Name* - as per MHN agreement
Delivery of School Based Youth Services
Decile
MHN - Primary Care services
GP FTE
RN FTE
0.025
Current FTE
TPU & ALT ED
places Nov 13
TPU & ALT ED
Hamilton's Fraser High School TPU*
1
Huntly College*(vacant 18/10/13)
1
0.05
Pa Harakeke Teen Parent Unit (Tokoroa HS)
1
SCOPING
Te Wharekura o Rakaumangamanga
1
Raukura Hauora
Te Wharekura o Te Kaokaoroa o Patetere
1
SCOPING
Te Wharekura o Te Rau Aroha
1
SCOPING
Manaia School (Thames) Note this is a primary
school
Ngaruawahia High School*
2
2
0.05
0.4
0.2
Paeroa College*
2
0.05
0.4
Taumarunui High School*
2
0.05
0.6
Te Wharekura o Maniapoto
2
SCOPING
Tokoroa High School*
2
0.05
Coromandel Area School
3
SCOPING
Forest View High School
3
0.05
0.5
Nga Taiatea Wharekura (HIGH NEEDS POP)
3
0.05
0.6
Putaruru College
3
Tai Wananga - waiting for D3 funding
3
Te Kuiti High School ( Advertising)
3
0.05
Vacant
Waihi College
3
0.05
0.4
Fairfield College
4
Fraser High School
Number of
Nurses required
(FTE)
Total School
Roll May 2013
Ratio 1:750
ratio 1:200
0.2
33
0.165
No info
11
0.055
Number of
Education
Nurses funded nurses
required [FTE]
(FTE TBA)
324
0.43
0.01
108
0.14
0
28
0.04
0
25
0.03
0
30
0.04
5
0.025
214
0.29
0.1
11
0.055
281
0.37
0.1
10
0.05
391
0.52
0
11
0.01
20
0.1
548
0.73
3
0.015
52
0.07
18
0.09
451
0.60
0
271
0.36
0
391
0.52
0
185
0.25
11
0.055
324
0.43
7
0.035
727
0.97
0.1
0
864
1.15
4
0.1
0
1543
2.06
Melville High School - GP found, no rollout as focus
on Decile 3
4
GP found, no rollout
as focus on Decile 3
0.27
622
0.83
Nga Purapura o te Aroha
4
0
1
0.00
Otorohanga College
4
0.05
0.075
0
365
0.49
Piopio College
4
0.05
0.052
0
129
0.17
Raglan Area School - under GP standing orders
4
under GP standing
orders
0.015
129
0.17
St Andrew's Middle School (Hamilton) Note: Now
Hamilton Junior High School
Te Aroha College
4
0
42
0.06
4
0.1
0
353
0.47
Whangamata Area School(vacant)
4
vacant
0
144
0.19
Te Kauwhata College- recruiting
5
recruiting
0
340
0.45
Hamilton Girls' High School
6
0.05
0.015
1587
2.12
Hauraki Plains College
6
0.05
0.0375
0
696
0.93
Matamata College
6
0.05
0.0375
0
868
1.16
Mercury Bay Area School
6
0.05
0.0375
3
0.015
346
0.46
Morrinsville College
6
0.05
0.025
15
0.075
733
0.98
Te Awamutu College
6
0.075
SRC starting
16
0.08
1149
1.53
Thames High School - Local GP to provide service
6
Local GP
0.025
0
614
0.82
Sacred Heart Girls' College (Ham)
7
0
927
1.24
St John's College (Hillcrest)
7
0
770
1.03
Cambridge Middle School
8
0
3
0.00
Hamilton Boys' High School
8
0
2188
2.92
Hillcrest High School
8
0.085
1661
2.21
Berkley Normal Middle School
9
0
24
0.03
Cambridge High School
9
0.4
Public Health
Nurses FTE or
equivalent
See Tok HS
0
2
0.2
0.025
0.5
No info
0.025
0.1
0.0375
54
0.2
0.05
3
0.052
3
DISESTABLISHED
TERM 4 2013
DISESTABLISHED
TERM 4 2013
0.075
17
0.05
0.9
0.75
0.625
No info
0
1428
1.90
Hamilton Christian School
9
0
279
0.37
St Paul's Collegiate (Hamilton)
10
0
659
0.88
St Peter's School (Cambridge)
10
0
1076
1.43
No info
Waikato Diocesan School For Girls
10
0
681
0.91
1.0
Note - there are 5 students in Kawhia enrolled with
correspondance school
N/A
0.05
4.3
0.6
0.479
5
0.025
247
1.235
24582
32.78
28
3.275
AE Managing schools
Name of School
Coromandel Area School
Forest View High School
Hamilton Girls' High School
Hillcrest HS *Kauri Centre
Huntly College
Kawhia *Students enrolled at Correspondence School
Melville HS
Mercury Bay Area School
Morrinsville College
Ngaruawahia HS
Paeroa College
Raglan Area Shool
Taumarunui HS
Te Awamutu College
Te Kuiti HS
Te Wharekura o Rakaumangamanga
Waihi College
Total
Teen Parent Units
2013 - 2015
Number of
places
Name of School
Fraser High
School
Tokoroa High
School - Pa
Harakeke Teen
18
Parent Unit
3
17
Total
11
5
54
3
15
5
11
3
10
16
11
2
7
194
3
2013 - 2015 Number of
places
33
20
53
29
Appendix 2
Gap analysis
Total Nurse needed at 1:750 ratio
Total Actual Nurse FTE
GAP
32.78
4.779
28.1
1-3 decile nurses needed at 1:750
Actual nurses 1-3 decile
GAP
4-6 decile nurses needed at 1:750
Actual nurses 4-6 decile
GAP
5.81 GAP
4.1875
1.62
Alt Ed nurses needed
14.03 Actual Alt Ed nurses
0.4115 GAP
13.62 No info for Huntly college
7-10 decile nurses needed at 1:750
Actual nurses 7-10 decile
GAP
12.93
0
12.93
TPU & Alt Ed nurses needed at 1:200
Actual TPU & Alt Ed nurses
TPU nurses needed
Actual TPU nurses
GAP
No info for Tokoroa HS
1.235
0.6
0.625
0.97
0.4
0.57
0.265
0.2
0.065
30
Appendix 3
Reference Group Members

Dr Polly Atatoa Carr, Public Health Physician, Child Health Service & Associate
Director of Growing Up in NZ

Jennie Carey, School Nurse

Marg Carey, Rural and Community Services Manager, Health Waikato

Dr Bronwyn Campbell, experienced school GP

Jill Dibble, Group Manager, Rural & Community, Health Waikato

RoseMarie Edlin, Charge Nurse Manager, Thames Hospital

Dr Dave Graham, Clinical Unit Leader for Child Health

Anne Green, Public Health Nurse, Te Kuiti Community Services

Jane Hudson, Project Manager, Waikato DHB Planning and Funding

Maree Munro, General Manager Community Services, Midlands Health Network

Manaaki Nepia, Te Puna Oranga

Linda Rademaker, SBHS Review Clinical Lead (Chair)

Ruth Rhodes, Senior Portfolio Manager, Waikato DHB Planning and Funding

Dr Damian Tomic, Medical Director, Midlands Health Network

Lindsey Webber, Director of Nursing, Midlands Health Network

Freda Wilson, Ministry of Education
31
Appendix 4
Common themes from stakeholder feedback
School principals

Universally consider the service valuable and appreciated

Identify access issues for some students if no SBHS

Important connection with the wider community

Identifies health issues that would otherwise be missed and impact on achievement
and retention in school

Relationship between SHBS providers and school important

Generally would like more FTE, particularly GP

Recognise less than ideal facilities in many schools

Broader range of health providers would be beneficial
School clinic staff (managers, RNs, GPs)

Feel many students they see would not otherwise have access to care

Identify need to use limited time efficiently and effectively by RN/GP working closely
together

Concern that students may default on referrals

Sometimes degree of conflict between school and health provider approach and
policies not aligned

Continuity of care and referral back to own GP important, and essential to develop
good connection with local general practices

Dental care a concern

Identifying a lot of need in HEEADSSS

Facilities could be better in some schools

Access to medication a concern
Students

Most aware of the service, although still gaps

Most important is that it is free, frequent, accessible, convenient, private and
confidential

Visibility of RN/GP as part of school community is important

The right person, someone they can relate to and who is approachable is important
32
Appendix 5
Monitoring Framework
Formative evaluation
(Items in italics are additional to the Tier 3 Service specification).
Evaluation of the process of the current Review of School Based Health Services delivered
as a qualitative report:

Were the all right people involved in the reference group and other consultation?

Was all the appropriate information available and taken into account?

Do the recommendations reflect the best model to provide the most equitable service
within current resources for secondary school students in the Waikato?

Do the recommendations provide for an integrated service that is accessible and
effective within the funding parameters?
Ongoing formative evaluation
6 monthly reported by the DHB and including:

Progress in planning and preparation for the Services; timelines and any delays or
risks; and the steps taken to mitigate any delays or risks

Progress on service continuous quality improvement for each Facility, as per the
quality improvement plan

Plan to implement SBHS in eligible facilities that do not yet receive the Service

The key findings of the latest health needs assessment for each Facility

Health promotion activities completed for each Facility

Progress on completing universal screening assessments (HEEADSSS) in the
calendar year to date for all eligible students (all year nine students and all students
in teen parent units and alternative education facilities.

Total SBHS nurse leader FTE RN/PHN SRC

Total School GP leader to FTE GP
33
Process evaluation
A qualitative evaluation of who uses the service and of service delivery.
Reported by SBHS provider to DHB quarterly.
1. A register of all service users to include:

Family and first name

Date of birth

Parent/guardian/caregiver’s name and address

General practitioner’s name and address

Date of referral to service

NHI number

Ethnicity

Gender

Next of kin’s name and address

Date of each contact with the service

Date of exit from the service
2. Service providers:

Registered Nurse FTE per facility

Ratio RN FTE to School roll

GP FTE per facility

Ratio GP FTE to School roll
3. Service users:

Year nine roll total

Number of year nine students who have received a universal screening assessment

Number of year nine students who have had student or nurse initiated individual
visits for any reason

Years 10-14 roll total

Number of year 10-14 students who have had student or nurse initiated individual
visits for any reason

Alternative education and teen parent unit roll totals

Number of alternative education and teen parent unit students who have received a
universal screening assessment
34

Number of alternative education and teen parent unit students who have had student
or nurse initiated individual visits for any reason

% school roll accessing SBHS – total, by decile and by ethnicity, and compared to
the overall school population by decile and ethnicity
Outcome evaluation
A qualitative evaluation of what happened as a result of student contact with the service and
of subsequent health improvement.
Reported by SBHS provider to DHB quarterly:
1. Record referrals that arise from any nurse visit, including referrals that arise out of
the HEEADSSS assessment
2. Total number of students referred to external services (total students not referrals)
3. Total number of referred students who received external services
4. Number of student referrals to external providers:

GP (excluding sexual health)

Hospital or community accident and medical centre

Mental health services (excluding guidance counsellor and for suicidal ideation)

Mental health services for suicidal ideation

Drug and alcohol services

Sexual health services

Vision services

Hearing services

Physiotherapist (excluding on-site physiotherapist)

Oral health services

Community youth or social workers

Child, Youth and Family services

Other services (not listed)
5. Number of students referred to other health or social services within the school (total
students not referrals) to:

Guidance counsellor – drug or alcohol related

Guidance counsellor – abuse and neglect related

Guidance counsellor – mental health related

Guidance counsellor – other

School social worker / community worker

Physiotherapist provided on-site
35

GP provided on-site
6. Number of students provided school based nurse-led advice or treatment in relation to:

Chronic conditions care

Mental health

Abuse, maltreatment or neglect

Accident / injury

Drug and/or alcohol

Sexual health

Smoking

Dermatology

Nutrition / weight management

Gynaecological (not sexual health)

Gastroenterology

Neurology

Ear, nose and throat (not injury)

Ophthalmological (not injury)

Musculoskeletal

Other (not listed elsewhere)
7. Number of student pregnancies
8. Measures of health gains

Referral rates compared to estimated population expectations for

Mental health services

Drug and alcohol services

Sexual health services

Smoking cessation
36
Appendix 6
Project Board
Project Board
Name
Role
Brett Paradine GM Planning &
Funding
Executive – Senior Customer1
Damian Tomic
Senior Supplier2
Midlands Health Network
Maree Munro
Senior User3
Midlands Health Network
Lyndsey Webber
Senior Supplier
Midlands Health Network
Manaaki Nepia
Project assurance4
Te Puna Oranga
Freda Wilson
Project assurance
Ministry of Education
Jill Dibble
User/ Project assurance
Community Services
Ruth Rhodes
Customer
Planning & Funding
Julie Wilson
Customer
Planning & Funding
Project Manager
Jane Hudson
Planning
&
Funding
Project
Manager – project management
advice and support
Clinical Lead
Linda Rademaker
Contractor
–
consultation,
facilitation and report writing
Communications
Kathy Jenkin
Communications advice
1 Customers are defined as those who have commissioned the work and will benefit from the end results
2 Suppliers are defined as those that provide specialist resources/skills to the project
3 Users are defined as those who will operate the final product
4 Project assurance – this role ensures that the product covers all interests and is fit for purpose
37
Glossary
Alt Ed
Alternative Education
BPAC
Best Practice Advocacy Centre
DHB
District Health Board
FTE
Full Time Equivalent
GP
General Practitioner
HEEADSSS
Home Education and Employment. Eating. Activities. Drugs.
Sexuality Suicide and Depression safety. (Assessment Tool).
MedTech
IT practice management system
MHN
Midland Health Network
MOH
Ministry of Health
NHI
National Health Identification
NP
Nurse Practitioner
PHN
Public Health Nurse
PHO
Primary Health Organisation
PSO
Practitioner Supply Orders
RN
Registered Nurse
SBHS
School Based Health Service
SRC
Self-Referral Clinic
TPU
Teen Parent Unit
Waikato DHB
Waikato District Health Board
WALT
Waikato Alliance Leadership Team
38
SCHOOL BASED HEALTH
SERVICES REVIEW
Waikato District Health Board
26 March 2014
Purpose
1. To ensure current services are integrated to provide a
coherent service, prioritised to those who need it most
2. To recommend the best option for the future state of school
based primary health care services for Waikato secondary
schools within current funding levels
3. To describe clear referral pathways to other primary and
secondary health services (both to those delivered in schools
and those delivered in other settings)
4. To recommend a staged transition from current state to future
state
5. To ensure key stakeholders are involved at all stages of the
review
1
Current Service Analysis
1.
2.
3.
4.
Service gaps and anomalies
Opportunities for collaboration and coordination
Information gaps
Need for operational support
Proposed model
1. Re-focus of services
• Deciles 1-3,Teen Parent Units, Alternative
Education
• Deciles 4-6
• Deciles 7-10
2. Monitoring and Evaluation
3. Governance and Leadership
4. Professional development and support
5. Pathways and decision support tools
2