Examination of Witnesses (Questions 700-719)
MS JOY
WINKS AND
MS SARAH
DAY
7 MARCH 2007
Q700 Viscount Simon: What is the
role specifically of the school nurse and teacher when there is
an allergic emergency? How do they cope?
Ms Winks: The nurse in the mainstream state
schools will not be present.
Q701 Viscount Simon: Teachers?
Ms Winks: So the teacher and the staff in the
classroom or the dinner ladies, whoever is actually present, will
have been taught and trained and practised with a dummy EpiPen,
if it is an EpiPen, or knows that the child had an inhaler and
they will follow the child's individual plan.
Ms Day: I would probably say a high degree of
anxiety at each emergency, whether it be for the teacher or for
the nurse because it is a life-threatening condition, and you
have the protocols and you have your training but it is not something
that you are dealing with every day and, like everything, there
is a high level of anxiety to get them to hospital care as quickly
as possible.
Q702 Lord May of Oxford: What actually
is the incidence of these sorts of happenings because you have
just heard Dr Rosenthal talk about—or in fact maybe I read
it in this—the countless EpiPens he has prescribed and he
is only aware of one of them being used. What are we talking about
here with people having to use an EpiPen at school? Once a year,
once every few years, once a month?
Ms Winks: In my experience I have never known
one used and I am from a large city.
Lord May of Oxford: This is a not irrelevant
problem.
Q703 Lord Rea: In fact, do you feel
that school nurses are sufficiently well-informed on how to deal
with emergencies?
Ms Day: I would say probably on emergency training
as nurses if we are giving vaccinations we are expected to have
anaphylactic training every year. However, there are not any standards
that I am aware of across the nation as to the exact amount of
training we should have so it varies again from individual nurse
to an individual area as to what training you are actually getting.
At the moment accessing funding to training is a problem both
across the state and independent sector.
Ms Winks: Virtually across the nation at the
moment school nurses are not being allowed to go on training,
even the training for their specific degree course, for their
professional training; places have been cut.
Lord Rea: This is rather different from
the evidence we have had.
Lord May of Oxford: It is just as well
they are not using the things that they need to be trained for
that they are not being trained for, is it not?
Q704 Lord Rea: We heard evidence
from Mr Wells from the Department for Education and Skills that
"any nurse who administers an immunisation in a school setting
will receive anaphylaxis update training on an annual basis. That
is a requirement of their own continuing professional development."
Is this an aspiration or reality? Who provides the training?
Ms Day: Where you can get it from.
Ms Winks: Some primary care trusts provide the
training in-house and that is why we still get it. I am fortunate
that I come from a city with a children's hospital and so we access
the allergists for our anaphylaxis training, but it will be done
in-house so, yes, it is right we do have to do it and anybody
administering vaccinations will have that training, that is standard,
but it will be in-house.
Ms Day: Again, as independent school nurses
we do not have any line management or medical management as such
so we are having to buy into services all the time for training.
Obviously each nurse is accountable but it can be a problem to
try and access into the training courses depending on where you
are.
Q705 Lord Rea: Could you explain
again what you mean by "buy into"?
Ms Day: We have to pay for our training so that
we can practise because we do not come under the NHS, we are employed
by the schools.
Q706 Lord Rea: So it is the Department
for Education and Skills who pays?
Ms Day: Yes, our school environment will pay
for our training.[1]
Q707Lord Colwyn: But when you give a vaccination
I assume you know which ones are slightly risky and which ones
are not?
Ms Day: With any vaccination anyone can react
at any time to anything. Obviously there are protocols and guidelines
for vaccines but anybody having a vaccination could react at some
point, in theory.
Q708 Lord May of Oxford: I gather
that in 2005 the Department for Education and Skills produced
a guidance document for schools—and they are very good at
producing documents—called "Managing Medicines in Schools
and Early Years Settings" suggesting that children with particular
medical needs should have an individual health care plan. Who
actually draws these plans up and do you think that the following
through to make sure that all staff are aware of them is as it
should be?
Ms Winks: No, it is not as it should be. There
are again huge variations across the country. From my own experience
of school nurses it is in their core programme which is agreed
with the Education Committee that we do other care plans and we
do do that and the schools will have a process for staff knowing
which children have got care plans.
Q709 Lord May of Oxford: Do you think
the document itself is satisfactory? I spent five years, in a
curious way, as a civil servant and I found some of the things
quite useful and some of the things were a most tremendous waste
of paper and effort (although it did provide employment!) Do you
think this particular document is a good and useful one?
Ms Winks: It is useful but I do not think it
was ever meant to be used in its entirety otherwise you would
waste an awful lot of time and paper. Because it is an individual
care plan you are expected to pick out the individual parts of
it. A health professional is definitely at an advantage when you
are trying to pick out what is necessary.
Q710 Lord May of Oxford: How aware
are parents of this and what sort of interactions do you have
across the range of parents, who I imagine can range from those
who are insufficiently concerned to those who are excessively
concerned?
Ms Winks: We totally work with the parents;
we have to, they are the experts in their children.
Q711 Lord May of Oxford: What is
your experience of doing that? Does that seem to you to work well
on the whole?
Ms Winks: Like I say, there is a huge variation.
We will have to do home visits on some to get the care plan done.
Others will come into school willingly or meet at a health centre.
Obviously if a parent is not going to help you with it, you can
end up looking at the child protection side of things because
there is a need for that child to access school, so you need to
work in partnership with people from education and other areas.
Q712 Lord May of Oxford: But on the
whole you feel this thing is working okay, this particular bit
of the whole thing?
Ms Winks: There are huge variations. It will
be working very well in some places and not in others. They may
not know where to find it on the bookshelf in some schools.
Q713 Chairman: How much is the influence
of the parents' use of complementary practitioners outside the
NHS impacting on your drawing up of care plans with the parents?
Ms Winks: I have to say in the mainstream state
side it is not something that I have come across or something
that I have heard nurses up and down the country talking about.
Ms Day: I think in the independent side you
go with the parents and if you are finding that that treatment
is not working, as a health professional you can recommend other
areas or perhaps turn back to the medical side and advise them
where to go, so that is more on an advisory state but it is a
question of managing. The problem as well, as we have heard before,
is the communication down from specialists. We rely on the parents.
We are not jumping straight to their GPs or straight to a specialist
practitioner and we find it very difficult to access perhaps all
the right information on which to make a validated care plan for
the children. In boarding schools as well with an increasing number
of overseas students obviously communication there is a real problem.
We have language barriers as well as cultural differences and
whereas we might say that the instances of peanut allergy are
not high they do have a lot of rhinitis and hay fever and other
allergies which we are trying to manage.
Q714 Lord Selborne: I would like
to come back to EpiPens, which we talked about in the earlier
session as well. You have already told us that they are very rarely
used in your experience or the need rarely arises, but we are
also advised that they are prevalent and they are widely prescribed,
so there must be quite a lot of them knocking around the schools
and there is not a school nurse in the maintained sector, so it
is going to be the teacher ultimately on the rare occasions when
it is used who will have to supervise it. We have been told by
the Government that there is no reason why the teacher should
not deliver these EpiPens. Do you think that this is appropriate
and do you think they are stored appropriately in the school environment?
Ms Winks: There is absolutely no reason why
anybody should not administer it if they actually are there. There
will be a protocol for somebody staying with the child and somebody
going and fetching the EpiPen if it is held in a certain place.
There is no reason at all why a teacher should not administer
it, but then there is no reason at all why a dinner lady or a
caretaker should not administer it either. It will depend on who
is at the scene at the time. As for storage, it varies hugely.
In small schools they tend to be kept in one place and the staff
know exactly where to go and they send a runner. In a huge comprehensive
on different sites you cannot possibly do that, so the young person
is usually encouraged to carry it with them.
Q715 Lord Selborne: Are there national
guidelines which would be easily available?
Ms Winks: The Anaphylaxis Campaign do issue
some guidelines and they can offer training, if people can afford
to buy it, so there are some but it is only from the charity,
the Anaphylaxis Campaign. As far as I know, there are not any
national—
Q716 Lord Taverne: Can I come back
to your earlier answer. You say you have never actually known
of a case in which it has been used. That is over how many years
and with how many schools?
Ms Winks: I have been a school nurse in Sheffield,
in a large city, for 15 years and we had very few EpiPens when
I first started, in fact it was not something that we encountered,
and gradually over the years we now have a lot of EpiPens.
Q717 Lord Taverne: So how many schools
would that cover? In 15 years you have never known one used?
Ms Winks: There are 70,000 school children in
Sheffield.
Q718 Lord Taverne: Over 15 years
they have never been used to your knowledge?
Ms Winks: No.
Q719 Lord Selborne: I wonder if Sarah
Day can tell us whether you think in the independent sector they
are more prevalent or less prevalent.
Ms Day: I have a school of 400 pupils and six
have been prescribed EpiPens, and that is various ages. The youngest
is five with an EpiPen up to the oldest being 18, mainly for nuts,
but also for a bee or wasp sting for one of them. None of those
have actually had anaphylaxis to then be prescribed an EpiPen
at any time. That comes to the attitude that sometimes it can
get a bit like asthma where they do not carry their EpiPens with
them because they do not know what it is like to experience something,
so perhaps we are prescribing when they do not need it, I do not
know. Or maybe it is better to have something there for emergency
rather than nothing at all. I would like to suggest something
because if you think about it you have schools which have got
all these EpiPens flying around everywhere, and it is the same
with Ventolin inhalers, which you may know are for asthma emergency
care, and if every pupil with asthma and anaphylaxis are prescribed
then the schools are loaded with drawers full of inhalers and
EpiPens which need to be accessible; there is no point in locking
them away otherwise they are not accessible. Because they are
a prescription-only medicine there is also an issue that you cannot
have a stock, so for our premises where there is a school nurse
or even in the state school it would be good to be able to have
an EpiPen and a Ventolin inhaler for emergency use but we cannot
because they have to be on a prescribed basis for a prescribed
patient. I think that is something that could be looked at for
schools in order to prevent a lot of expense to the NHS on prescriptions
and it would be quite a simple thing to enable schools to do.
Ms Winks: Wherever there is a medical practitioner
or nurse on site then you could do that, but it would be a different
ball game for a teacher to be making a decision to use a stock
bottle of something.
1 Following the evidence given by Ms Day, the Royal
College of Nursing wished to clarify this statement. The Department
for Education and Skills is not responsible for training, but
nurses employed by local education authority schools may get funding
from the DfES. For further information please see the supplementary
evidence from the Royal College of Nursing. Back
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