The objective of the report was to assess how school health care services can be used to prevent children’s mental health problems and support their wellbeing. School health care is able to fairly easily address children’s problems, but there are deficiencies in the referral and communication systems. This document contains a summary of the main results of the audit. The entire audit report is available only in Finnish.
By preventing mental health problems and ensuring early intervention, we can address problems before they become severe, lower the risk of reduced functional capacity and eliminate the need for more expensive services. The objective of the report was to assess how school health care services can be used to prevent children’s mental health problems and support their wellbeing.
The study was limited primarily to services provided to children in the lower level of comprehensive school. Functionality of student welfare services in the detection and treatment of children’s mental health problems was also studied. In this study, the term ‘student welfare services’ refers to the services provided by school health care services, school welfare officers and school psychologists, as well as communal student welfare work at school.
Services provided by parties outside the school are also important in the treatment of children’s problems and in the support offered to their families. Therefore, cooperation practices between parties inside and outside schools were also studied. Another studied issue was whether any mental health work takes place in the everyday living environment of children.
School health care is able to best detect children’s mental health problems in connection with extensive physical examinations and through cooperation with the pupils, their families and the adults who work at the school
In the case of mental health issues, school health care mainly focuses on prevention, detection of problems, support and referral to treatment. Children’s mental health problems are detected in physical examinations at school to a varying degree. Problems are sometimes overlooked in annual physical examinations by school nurses, but there are better opportunities to detect mental health problems in more extensive physical examinations conducted in cooperation by school nurses and physicians. The content of such extensive physical examinations has been improved by means of nation-wide control, and data about the family situation of pupils is more systematically collected by interviewing the pupils themselves, their parents and their teachers.
In addition to physical examinations, problems can be detected when pupils visit the school nurse, during free-form interaction with pupils and during cooperation between student welfare services and teachers within the school. Commitment of all the adults at school is necessary to ensure that problems are detected. Cooperation with teachers is important, in particular, to ensure that information about any problems with the group or with specific individuals is mediated to the other parties active in school health care and student welfare.
School nurses are basically capable of detecting problems and referring pupils to treatment, but sometimes they lack the expertise needed to support children, particularly those experiencing mental health problems. The available physician resources vary a great deal between municipalities and regions. Not all of the schools have the same opportunities to detect problems, as there are considerable differences in the student welfare resources and operating methods between different areas and different municipalities.
School health care is able to fairly easily address children’s problems, but there are deficiencies in the referral and communication systems
Addressing pupils’ problems is a key duty school health care services. School nurses work close to the everyday life of the school and the pupils. Sometimes school nurses feel inadequate because they do not have the opportunity to pay enough attention to the pupils’ problems. Annual physical examinations for different age groups and administrative duties take up a large share of a school nurse’s resources. School nurses deem the current schedule of physical examinations for schoolchildren fairly hurried. There is not always enough time to support those who need it. The nurses feel that their regular duties prevent them from offering flexible services and support in the case of sudden problems. The school nurse can usually be quickly contacted, however.
In schools, the different parties active in the field of student welfare services – the school health care professionals, school welfare officers and school psychologists – cooperate and support each other. On the other hand, the practices used by the schools vary and there are some uncertainties and overlapping areas in the division of duties. Application of the privacy protection principles included in the Student Health Care and Welfare Act (oppilas- ja opiskelijahuoltolaki) that entered into force in 2014 has made cooperation between the different parties at school more difficult and even caused the abolishment of some cooperation practices. Unclear interpretation of the privacy protection principles included in the Student Health Care and Welfare Act continues to hamper the sharing of information about pupils and the communication between the student welfare actors.
In the case of more complex mental health problems, a pupil is referred to parties outside the school for assessment and treatment. There is often a delay in the access to these services, which means that the school’s student welfare services must support the pupil at school. Pupils usually receive treatment quickly in the most acute cases, however. There are regional and municipal differences in the practices and processes applied to outside treatment and referrals and in the number of patients waiting for treatment, and the links between different services are not always seamless. There is room for improvement here to ensure that children will have fluent access to treatment instead of being transferred from one party to another due to complex procedures. There is room for improvement in communication between the service providers and student welfare services as well in order to ensure that information about a pupil being treated or receiving support, as well as the necessary further actions, will reach all of the parties active in the school’s student welfare system.
Functionality of student welfare services and standardised operating methods must be verified in connection with the social welfare and health care reform
If the proposed health, social services and regional administration legislation reform is implemented, regional authorities will carry the responsibility for the arrangement of school health care services, while the municipalities will be in charge of basic education, school welfare officer and psychologist services as well as communal student welfare work. Arranging social and welfare services at the regional level would enable better integration between school health care services and basic and special social and welfare services. Meanwhile, functionality of the student welfare services as a whole must be ensured by promoting cooperation and agreements between regional authorities, municipalities and schools. A risk associated with the reform is the services becoming decentralised instead of integrated.
Cooperation between the Ministry of Social Affairs and Health and the Ministry of Education and Culture as well as governance are needed to integrate health care services, education services and social welfare services, as well as to ensure seamless service chains and fluent communication. This will ensure functional and standardised student welfare services in the whole of Finland. Governance by the Ministries is especially important in cases where a municipality or regional authority attempts to change the focus of student welfare services from one service provider to another. Such a situation is especially likely in the case of mental health issues where the division of duties and responsibilities between school health care services, school welfare officers and school psychologists at schools are unclear.
Recommendations of the National Audit Office
The Ministry of Social Affairs and Health and the Ministry of Education and Culture should ensure by means of proper governance that school health care services will become an integral part of the student welfare services at schools in connection with the social welfare and health care reform.
The Ministry of Social Affairs and Health should develop the multisectoral cooperation in school health care services to ensure seamless service chains and promote communication between the actors. Seamless services and ease of addressing problems could also be supported by providing specialised health care and social welfare services through schools.
The Ministry of Social Affairs and Health should develop the physical examinations arranged by school health care services and their scheduling so that the school nurses could use more of their resources to perform extensive physical examinations for specific age groups and to support pupils that need support.