(From UCLA School Mental Health Project) A new book in January 2015 by the UCLA School Mental Health Project makes a cogent argument for transforming the fragmented delivery of various support services so that they truly support student learning and equitable educational opportunity. The authors begin with this " external and internal barriers to learning and teaching have continued to pose some of the most pervasive and entrenched challenges to educators across the country, particularly in chronically low performing schools. Failure to directly address these barriers ensures that (a) too many children and youth will continue to struggle in school, and (b) teachers will continue to divert precious instructional time to dealing with behavior and other problems...Transforming student and learning supports is key to school improvement. To this end, this book incorporates years of research and prototype development and a variety of examples from trailblazing efforts"  They go on to say "Mapping a school district’s existing efforts to address problems yields a consistent picture of many practices and fragmented, piecemeal, and usually disorganized activity (as illustrated below). The range of such learning and student supports generally is extensive and expensive".  They also go on to describe the cause and this is where we might disagree: "Underlying the fragmentation is a fundamental policy problem, namely the long-standing marginalization of student and learning supports in school improvement policy and practice. Thus, most efforts to directly use student and learning supports to address barriers to learning and teaching and re-engage disconnected students are not a primary focus in school improvement planning. " In our view, a major cause of the fragmentation is that the mandates and funding of the various health, social and other services is done in a sporadic, competitive and disjointed manner. Part of the transformation will require that health and other ministries re-organize their work so that they are accountable for providing consistent support for students most at risk, rather than always worrying about the optimal health of all students in universal programs. There have often been attempts to insert health outputs and outcomes into school system accountability. In our view, this should be a two-way street, with health and other systems being accountable for a reasonable number of educational outputs, particularly for more vulnerable students. Read more>>

(From the ISHN Member information service)  A Chicago-based organization, the Healthy Schools Campaign, has emerged on the national scene in the United States and is working hard to influence national policy decisions. Working from a background paper/initiative, Health in Mind, HSC has formed an  influential group of organizational and government leaders called the National Collaborative on Education and Health, with an impressive list of members  The NCEH has gained access to the US Surgeon General's Advisory Group on Prevention, Health Promotion, and Integrative and Public Health (Prevention Advisory Group), which was created by the Affordable Care Act to bring a non-Federal perspective to the Strategy’s policy and program recommendations and to its implementation. 

On August 24, 2014, the NCEH hosted the first meeting of its Health Systems Working Group, an important step towards identifying strategies for redesigning health delivery systems to meet the health needs of students. The Health Systems Working Group members bring together over 25 health and education leaders who will work together over the next four months to identify strategies to increase collaboration between the health and education sectors to support the delivery of school health services and programs. Some of the key questions this group will address include:
• How can schools be incorporated into delivery system reforms; other new models of care emerging from the Affordable Care Act; and other innovations being tested for the delivery of physical and mental health services, health promotion and prevention?
• How can the health care system better support schools in creating the conditions of health for students?
• What new models of practice are needed in both the health sector and schools to support an integrated delivery of care model?
• What type of guidance needs to be shared with the health and education sectors to promote collaboration?

At the first meeting of the working group, participants discussed a brief discussion paper describing the opportunities presented by the Affordable Care Act that can be used to promote collaboration between the health and education sectors. The paper also discussed the need for a model that leverages these opportunities. These examples illustrated how preventive and primary care examples where hospitals/health care organizations from Portland, St. Paul, Madison, Grand Rapids, Deleware, Austin, Cincinnati and Kentucky are working closely with schools.

Commentary:
This is an exciting development within the United States. Coinciding with the release of the updated US school health promotion model from the Centers for Disease Control and Prevention and the educational leaders organization, ASCD, these policy level discussions could be connected to the renewed program and practitioner led efforts. They could also be built upon previous substantive work done on school health care services and centres in the US. Hopefully, these high level policy/advocate discussions will be connected firmly to the extensive history of programmic excellence.

Secondly, we hope that the discussions of this NCEH Working Group can be linked to broader discussions of how the health systems can support promotion and prevention policies and programs as well as preventive care through schools. As we know from the many different successful models of school health promotion in the US and elsewhere in the world, several aspects the public health functions of coordination, promotion, prevention, protection and surveillance can all be accomplished by working with and within school systems.  

As well, we hope that these policy/advocacy discussions on US health care-school programs can address the barriers and facilitators that health systems face when maintaining and sustaining long-term health promotion approaches such as school health. There is constant pressure on the health promotion sectors of health systems to respond to the latest health/social problem of the day. With scarce resources often drawn to treatment and emergency health, the health promotion sector is often forced to fund activities on a selected list of issues rather than on health overall. While this underlying problem of scarce resources will never disappear, there are systemic changes that can be made to structures, staffing and decision-making to ensure continuity and ongoing relationships/commitments to non-health sectors such as schools. A research agenda on such barriers and facilitators has already been proposed by a recent North American symposium of education and health leaders.  Another practical suggestion coming out of that symposium was greater and sustained investments in school nursing. If school nurses can be mandated to the full scope of their professional roles, then they can be be essential glue that keeps school health care connected to school health promotion and to the many specific prevention activities. 

A third hope for these high powered US discussions is that they take the time to truly understand the core mandates, concerns and constraints of school systems so that they can truly motivate and engage school systems in health promotion. Educators will happily accommodate health services in their schools. Indeed, this is often the first thing that school administrators ask for. Educators can provide all sorts of other health promoting support in their teaching, caring for children, working with parents and community leaders and more. But, as recent research is showing, they are reluctant to do that unless the health systems modify their approach to ensure that is it based on systemic, long-term strategies. ISHN and ASCD have gathered this recent research into a global discussion of how health (and other systems) need to integrate their programs within education systems. Insights and evidence-based and experience-tested ideas from the global discussion, including a consensus statement, a background paper and International Discussion Group are all sources that we hope American and other national leaders will not ignore.  

(An item from the ISHN Member information service) An article in Issue #4, 2013 of Journal of Health Organization & Management discusses how the unique professional identities and norms of physicians can hinder organizational improvements and developments. Since school health promotion programs usually and ultimately report to a physician who is the senior manager, this article should be of importance when seeking to modify health system approaches to schools. The authors found that "If managers want physicians to engage in improvements, they must learn to understand and appreciate physician identity. This might challenge managers' identity. The paper shows how managers – primarily in a Swedish context – could act to facilitate physician engagement. This in turn might challenge physician identity. Read more>>