General Principles


I. The Royal College of Nursing Wales welcomes this Bill and is strongly supportive of its aim to enhance the standard of care and education received by children and young people with Additional Learning Needs. 


II. Every child and young person has the right to access education and it is appropriate for the Assembly to consider how a new legislative framework can ensure that statutory agencies and professionals can best support children with additional learning needs. It is vital that any new legislation in Wales is up to the task of resolving many of the issues currently experienced by children and young people with ALN, and their families, and overcoming the variation in standards across the country. We therefore support the three overarching objectives (para 3.3 of the explanatory memorandum) and the subsequent ten core aims for the Bill. 


III. The Royal College of Nursing is also aware of the very many difficulties that children and young people with diverse healthcare needs face in order to continue access to education. We believe that more specialist nurses, including learning disability nurses and children’s nurses, are needed in the community, to provide the right type and level of care to children and young people at home, and in school. We have argued for a refreshed school nursing framework that allows senior school nurses with a leadership role, to coordinate the network of health services for school-aged children in a single locality. 


IV. We believe that the Welsh Government’s guidance “supporting learners with healthcare needs” is not broad enough in its scope or strong enough in its direction to achieve improvements. We are aware this guidance is due to be reissued by the Welsh Government shortly and we would certainly welcome a commitment from the Government to radically strengthen it first. The RCN is currently drafting guidance for members about supporting children and young people with healthcare needs in schools and we would be happy to share this with the Committee once it is published later this year. 


V. The Royal College of Nursing feels there should be parity between the requirement to meet a child’s health needs and meeting their learning and educational needs. This piece of legislation should be mindful of the fact that if a child’s health needs are not met, then they will not be able to learn or access education as they should. It is important, therefore, that the Bill approaches this in such a way as to allow the right healthcare professional with the right skillset to be deployed to best support the individual needs of the child. 


VI. It is important to note that the Bill itself was not drafted with the aim of addressing individual health or medical needs (please note that these terms are not interchangeable). Indeed, the three overarching objectives listed at paragraph 3.3 of the Explanatory Memorandum do not mention health, nor does the definition of ALN given at 3.5. 


VII. The endeavour to add this additional healthcare element to the Bill, creates an additional layer of complexity and a potential risk of unintended consequences in specifying too narrowly a new layer of duties on a discipline within healthcare that would not necessarily be best placed to deliver them. We are also concerned that if this new element is added to the Bill, many of our professional colleagues in medicine and therapies practicing within acute, community and primary sectors, should also be given the opportunity to contribute to the discussion. It would also be helpful to have the view of the Health Boards on the strategic development of these services. This is because the needs of children and young people with additional learning needs (as identified in this Bill), traverse a number of professionals and sectors, hence the need to understand how a change in one part of the system affects the services provided by another and protect against causing unintended consequences. 


VIII. We must ensure that we get the Bill absolutely right, and it is for that reason that the Royal College of Nursing believe that the Committee may wish to consider recommending to the Welsh Government (or introducing as a Committee Bill), a second, separate Bill, more specifically focussed on health care provision for children and young people. We make alternative suggestions about the approach that the Committee may wish to take throughout this response.


IX. Additional learning needs are not the same as healthcare needs and understanding precisely the needs we are endeavouring to meet via this legislation is fundamental to ensuring the right measures are established. In our answers to the further questions of the Committee below we elaborate on the different types of nursing support that might assist a child with additional learning needs and/or healthcare needs. 


X. We also at the end of this paper make a suggestion for an additional statutory duty on Health Boards to appropriately workforce plan to meet the needs of children and young people and to publish these plans. 


Provisions for collaboration and multi-agency working

XI. The Bill provides an excellent opportunity for strengthening collaboration between multiple agencies and enhancing information sharing. However, there is a need to ensure these duties do not create unnecessary bureaucracy and are not prescriptive in a way that either reduces the capacity of healthcare professionals to respond to the needs of the child or reduces the flexibility of the healthcare care service in selecting the right healthcare professional to meet the needs of the child. 


XII. The Royal College of Nursing has some concerns about the DECLO. Whilst we can see some possible positives in the creation of the role, there is also a risk that the role will divert healthcare professionals into providing an administrative service.  Section 55 (2) of the Bill states that:


A Local Health Board may only designate an officer who is—

(a) a registered medical practitioner, or

(b) a registered nurse or another health professional.


It is not entirely clear why a registered healthcare professional would be needed to undertake this role. Would one aspect of the DECLO role be carrying out the actual assessment of whether a child’s learning needs could be supported by a healthcare intervention? (In which case then that role would need to be undertaken a registered healthcare professional). There must be a clearer role description with clear lines of accountability and authority to influence, so as to ensure right provision for children and young people’s needs. Furthermore, it should be noted that if a registered healthcare professional is required then this term encompasses doctors, nurses and therapists. 


XIII. Most importantly the role of the healthcare professional needs to be clarified in the Bill. In places, the Explanatory Memorandum use the term healthcare and medical interchangeably (e.g. pages 169 and 186) and this illustrates the potential confusion over what precisely is needed. Different healthcare professionals, such as doctors, nurses and physiotherapists, provide different types of care. 


XIV. For the purposes of clarity, we are outlining below the different roles that nurses can play in the delivery of care for children and young people in an educational setting:


Health visitors

XV. Health visitors are specialist registered nurses who make a significant contribution to public health and the health and well-being of families and local communities. They monitor and assess the health and well-being of infants and young children, detect early any issues which require further action, assist parents in developing parenting skills and confidence, and help to connect them with further sources of support. They also often act as the first point of contact for all health and well-being and child protection issues for children under the age of five, and work with community groups and social services colleagues to promote health in the early years. 


School nurses

XVI. School nurses are specialist public health practitioners working across education and health, providing a link between school, home and the community to benefit the health and well-being of children and young people. They play an important role in regards to liaising with school staff to improve safeguarding within the school setting through multiagency working and highlighting concerns regarding children’s safety. The RCN has argued for a refreshed school nursing framework that allows senior school nurses with a leadership role to coordinate the network of health services for school-aged children in a single locality.  


Learning disability nurses

XVII. The Registered Nurse for People with Learning Disabilities is the only healthcare profession specifically trained to work with and support people who have learning disabilities. Learning Disability Nurses play a central role in the lives of many people who have learning disabilities and their families, particularly those with more complex care needs. Learning Disability Nurses work across a range of settings, with individual clients, in secondary healthcare and community based residential services. Learning Disability Nurses can also provide invaluable continuity for people during the period of transition from children to adult services, a time when those with learning difficulties can be particularly vulnerable. Learning Disability Nurses work as part of specialist teams in children’s services, challenging behaviour and inpatient services. The RCN has called for an increase in the number of Learning Disability Nurses in Wales particularly in those skilled to work with very young children and young people. 


XVIII. Registered Children’s Nurses in the Community 

As part of a community nursing team a registered children’s nurse might support individual children with specific conditions in maintaining their independence, and enjoyment of family and educational life. They can provide specific nursing interventions or nursing care, and may also provide much needed education and support for other workers and health care professionals in this arena. The Royal College of Nursing has been calling for some time for an increase in the number of children s nurses in the community. 


XIX. Specialist Nurses 

Some children and young people may have conditions that require support from a specialist nurses e.g. cancer or diabetes. Again these highly specialised nurses will also have a leadership responsibility in providing education to other nurses, healthcare support workers, and professionals in how best to support a children with this condition. 


XX. We hope it can be seen therefore that depending on the individual needs of the child and young person, which must be paramount, that flexibility will be needed to deploy the right nursing professional to provide the care and support that will benefit her or his additional learning needs. 

XXI. Therefore in placing a strengthened duty on the Health Board to meet the needs of the child maintaining this flexibility of deployment is critical. This would be even more critical if the Bill was to move from discussing a child with additional learning needs to a child with healthcare needs. 


Individual Development Plans


 XXII. The Royal College of Nursing Wales is broadly supportive of the concept of an IDP as a way of ensuring consistency and continuity and ensuring that plans are tailored to the individual needs of a child. It is important however that the legislation allows sufficient flexibility for the needs of the child to be met by the right professional providing the right level of care; who delivers the care must be determined by the specific needs of the child, not by a pre-determined pathway. 


Capacity of the workforce

XXIII. The shortfall in workforce capacity has been noted in evidence gathering sessions so far. The Bill provides an opportunity to strengthen the strategic workforce planning model in order to ensure that we have sufficient numbers of professionals (such as LDNs, community children’s nurses and other healthcare professionals) in the right fields to deliver the care required. Recruitment and retention of the workforce will be crucial to the success of this legislation, and this should be reflected on the face of the Bill.


XXIV. The Royal College of Nursing Wales would ask the Committee to consider a new section to the Bill.  This would place a new duty on Health Boards to reflect on the needs identified by the Individual Development Plans (perhaps as collated on an annual basis) and then ensure that this workforce need was reflected in the workforce plans submitted to Welsh Government. 


About the Royal College of Nursing

The RCN is the world’s largest professional union of nurses, representing over 430,000 nurses, midwives, health visitors and nursing students, including over 25,000 members in Wales. The majority of RCN members work in the NHS with around a quarter working in the independent sector. The RCN works locally, nationally and internationally to promote standards of care and the interests of patients and nurses, and of nursing as a profession. The RCN is a UK-wide organisation, with its own National Boards for Wales, Scotland and Northern Ireland. The RCN is a major contributor to nursing practice, standards of care, and public policy as it affects health and nursing. The RCN represents nurses and nursing, promotes excellence in practice and shapes health policies.