Content

RESOLVED:
That the Cabinet
Procurement & Insourcing Committee agrees an award of the City
and Hackney School Based Health Service contract to Provider A for
a period of up to five years (3+1+1) from the 1st of September
2024. The total value of the contract will be a maximum of
£7,300,000 (an average of £1,460,000 per year).
 
Reason(s) For Decision
 
5.1. The SBHS is available to all children and
young people aged 5-19 attending state-maintained settings in
Hackney and the City of London. There are currently 58
state-maintained primary schools, 16
state-maintained secondary schools, three
special schools, a
state-maintained ‘pupil referral
unit’, and one alternative provision-free
school. There is currently one
state-maintained primary school in the City
of London.
 
5.2. The SBHS was last procured in 2018. Since
then, there has been a
steady decline in the number of SCPHN-trained
nurses, and consequently,
numbers have reduced significantly.
Additionally, a high proportion of
nurses are nearing or close to retirement age.
Alongside this decrease in
the specialist workforce, there has been an
increase in the demand for
school nursing services, such as safeguarding
services and support for
CYP with SEND. A range of factors drive this
increase in demand,
including the COVID-19 pandemic, a sustained
period of austerity, and the
current cost of living crisis.
 
5.3. The number of children requiring school
places in the borough and the
City of London is reducing. However, the
number of children attending
school with potentially complex health needs
is increasing. This is due to
the implementation of a phased expansion of
school places for children
with SEND. The current service specification
includes a dedicated
specialist nursing service for CYP in special
schools and a requirement for
public health-trained nurses to support CYP's
holistic and clinical needs,
with SEND attending all state-maintained
schools. This approach is
problematic as it is inflexible to the
changing needs of the children and
young people within each school (which may
increase or decrease over
time), and it does not account for schools
opening or closing. Additionally,
there are concerns that children with complex
health needs in special
schools do not receive support from the
appropriate health professional
and through appropriate commissioning
arrangements.
 
5.4. Government guidelines for the HCP were
updated in 2021. The service
was redesigned to align with the most
up-to-date guidelines and to be
responsive to the population's health needs
and the changing context
described. The redesign also aims to
redistribute the resources of the
SBHS to enable focus on delivering universal
and targeted interventions
that seek to improve health and reduce health
inequalities for all
school-age children in maintained
settings.
 
5.5. The redesign of the SBHS also aims to
improve communication and
collaboration between the service, parents,
school personnel and
school-age children. Digitising elements of
service delivery and
streamlining processes will increase contact
and provide additional
opportunities for preventative and
health-promoting interventions, enabling
public health nurses to identify needs early
and influence behaviour
change. The changes to be introduced with the
new service design will
also aim to reduce the burden on schools when
sharing or receiving
information, improve efficiency, and reduce
risk.
 
5.6. Finally, the redesigned SBHS will be
configured at the neighbourhood
level, aligning the SBHS with the recently
procured Enhanced Health
Visiting Service and improving the handover
between services. Health
Visitors are responsible for leading the 0-5
element of the HCP. Alignment
at the neighbourhood level will also seek to
improve the interface between
school nursing and primary care.
 
6. Alternative Options (Considered and
Rejected)
 
6.1. Option 1: Do Nothing.
 
6.1.1. The current contract ends on 31 August
2024. Under the terms of the
Health and Social Care Act 2012, upper-tier
local authorities are
responsible for improving the health of their
local population. Local
authorities are also mandated to deliver the
surveillance elements of the
National Child Weight Measurement Programme
(NCMP).
 
6.1.2. While the termination of the service
would provide savings to the Council,not procuring an SBHS would mean the
local authorities would fail in the legal duty under the Children
and Families Act 2014 to support schools to ensure they look after
children with medical conditions. Overall, this option would put
the health of children and young people in Hackney and the City of
London at risk and would likely result in a widening of health
inequalities for the 5-19 population.
 
6.2. Option 2: Reprocure the service based on the current service
model.
 
6.2.1. The current service model is
unsustainable due to changes since the
service was procured in 2018; this includes
increased demand for
safeguarding, an expansion of school places in
Hackney for children with
SEND, and an overall reduction in the
availability of qualified public health
nurses.
 
6.2.2. The commissioning guidelines are clear
that responsibility for the funding of health services for children
with the most complex needs should be NHS funded. Reprocuring the service on the current model is
likely to
result in SCPHN nurses continuing to deliver
nursing services outside of
the scope of the HCP and reduce the capacity
of the service to focus on
other important aspects of public health
nursing, such as working
preventatively and in partnership to address
health inequalities for all
children aged 5-19.
 
6.2.3. Redesigning the model also requires
that the systems and processes for delivery are reviewed and
modernised to reduce risk and optimise service
delivery whilst improving patient safety.
 
6.3. Option 3: Recommission a new School-Based
Health Service based
on a new service model and specification and
maintain the current
budget for the service.
 
6.3.1. The guidelines for procuring the 0-19
HCP were updated in 2021.
Therefore, the new service model and
specification have been updated to
reflect the renewed commissioning guidance.
The revised model will also
provide opportunities for innovation and
digitisation of service elements to
derive efficiencies and increase safety.
 
6.3.2. The new service model and specification
ensure that the health needs of children with complex medical
conditions are met by the appropriate
health professional and that the commissioning
arrangements align with
recommended guidelines.
 
6.3.3. The revised model will position the
SBHS as leaders of the HCP and
ensure a greater emphasis on health promotion
and preventative activities
to support the health of all children, taking
a proportionate universalism
approach across the social gradient to reduce
health inequalities.
 
6.3.4. The new service model will continue to
support the local authorities and local schools to meet statutory
duties through improved delivery systems,
including ‘supporting children at school
with medical needs’ and the ‘NCMP’.
 
6.4. Option 4: Insourcing the School-Based
Health Service based on a
new service model and specification and
maintain the current budget
for the service.
 
6.4.1. As described in the
insourcing/outsourcing options appraisal (Exempt
Appendix 4) attached to the HPB business case
for this service, there are
several reasons why the decision to insource
was rejected.
 
6.4.2. The SBHS is a clinical service led by
special community public health
nurses. The nurses are registered with the
Nursing and Midwifery Council
and must fulfil the legal and professional
requirements for registration and
validation. The service provider must have the
policies and procedures in
place to ensure adherence to clinical
standards and appropriate and
effective clinical supervision of staff. A
health provider has the structures
in place to ensure that services are delivered
per clinical standards and
that the workforce is supervised appropriately
in line with the NMC code of
practice. Establishing a similar management
structure in the local authority
for a nurse-led clinical service will likely
incur additional costs from within
the existing budget, resulting in reduced
funding to deliver frontline
nursing services in schools.
 
6.4.3. Insourcing the service will also
require investment in a suitable ‘patient
record system’ or
‘database’, such as Rio for case management and
related software, and systems to deliver
service elements such as the
National Child Weight Measurement Programme.
The costs associated
with a patient record system alone were shared
in the business case and
relate to both the startup and ongoing costs incurred for service
and
maintenance.
 
6.4.4. The small number of boroughs that have
insourced their school nursing service have reported a high
dependency on bank staff, which are more expensive. Insourcing the
service could, therefore, mean that the local
authority would incur additional costs
associated with a high dependency
on bank staff. There is currently a national
shortage of qualified SCPHN
nurses in the country, impacting the
recruitment and retention of qualified
nurses. Competition for the nursing workforce
in London is high, with
boroughs competing for the same pool of
qualified registered nursing staff.
SCPHN nurses are predominantly employed in the
NHS and receive their
salaries, including pension and benefits,
through Agenda for Change
(AfC). Qualified
nurses have a choice of providers to work for in London;
additional incentives, such as higher wages,
encourage staff to move
away from the terms and conditions afforded by
AfC, including continuous
service. In addition, the local authority must
meet the incremental uplift for
AfC when a service
is insourced.
 
6.4.5. There are also risks directly related
to insourcing the service, including the impact that insourcing
will have on the delivery of statutory aspects of the
service, such as the surveillance element of
the NCMP, an annual process
commencing at the start of the school year.
Elements of the SBHS
structure, including the multi-agency
safeguarding hub (MASH), will
continue to be located within the structures
of the local health provider.
Insourcing the service is likely to disrupt
safeguarding, which relies on
effective collaboration and handover between a
wide range of partners in
health and social care, including the Health
Visitors delivering the 0-5
element of the HCP.
 
6.4.6. As described in the
insourcing/outsourcing options appraisal, aspects of the service
are already insourced. Public Health, via a service level
agreement funds Young Hackney to deliver the
Health and Wellbeing
service. This service aims to support schools
in meeting statutory duties to
deliver Relationship and Sex Education (RSE)
education alongside
Personal Social Health and Economic (PSHE)
education in schools.
Supporting schools with the delivery of health
education is a key
requirement of the HCP. Young Hackney youth
services were considered
to have the more appropriate personnel to
relate to children, particularly
teenagers, to deliver training and education
on health and wellbeing, with
the school nurses focused on delivering
clinical services. The new
contract will strengthen the relationship
between school nurses and Young
Hackney.
 
6.4.7. Any procurement must factor in the lead
times required to explore the
evidence of safe and effective models of
insourced services, including
identifying suitable resources, management
structures and systems to
enable the delivery of an in-house
school-based health service in the
future.