The recent health and social care committee evidence session on improving health engagement in education, health and care plans (EHCPs) asked the question: where’s the H in EHCP? Hearing this took me back to a 2019 conference with that title. It was not just déjà vu, it was despair and disappointment. For more than a decade, the same concerns have been raised about weak health accountability. But these are not simply isolated implementation failings. They stem from structural gaps in NHS services that strengthened oversight cannot fix. The NHS is responsible for meeting the health needs of children with medical conditions, including long-term conditions and disabilities, as the schools minister recently confirmed. But there is no national service model for the NHS to deliver on these responsibilities. Without it, the opportunity to get this right will be missed. NHS service gaps In 2013, commissioning for public health, including school nursing, moved from the NHS to local authorities, while the NHS retained responsibility for clinical services, creating a gap in school services. Around this time, section 100 of the Children and Families Act 2014 came into force, often interpreted as a catch-all duty for schools to support medical conditions, even when it involves clinical healthcare. The scale of the gap is striking. In 2025, I sent a freedom of information request to all 42 Integrated Care Boards (ICBs). Of the 40 that replied, only eight (20 per cent) said they commissioned comprehensive clinical nursing services for children in mainstream schools. However, the follow-up responses showed this was not entirely accurate, as most relied on schools delivering nursing care. Only three (8 per cent) indicated services delivered all nursing care, but this could not be confirmed due to limited detail. A generous view, assuming the three responses were correct, would still mean over 90 per cent of ICB-commissioned services failed to meet children’s clinical nursing needs in mainstream schools. Many ICB responses referred to responsibilities sitting with local authorities’ school nursing, highlighting a concerning lack of understanding of the distinction between NHS clinical and local authority public health responsibilities. Reforms and rights What is disappointing is that the SEND reforms and the recently issued draft medical conditions guidance do nothing to address the gaps. Instead, they appear to embed the health failings and education fixes. This not only has implications for all involved, but it is a fundamental failure of children’s rights. The DfE carried out a child’s rights impact assessment for the SEND reforms, based on the UN Convention on the Rights of the Child. Article 24 sets out the right to the best standard of health and the health services needed to achieve it. However, in several areas, impact against article 24 was not assessed, including national inclusion standards and accountability. According to the DfE, where an article was not referenced, it was “not relevant”. The draft medical conditions guidance makes inclusion its overarching principle. But this focuses on article 28, the right to education, with no reference to article 24. It proposes school-owned healthcare plans with clinical content and extended responsibilities for schools, including staff training and assuring competence in clinical nursing procedures. It also presents a narrowed view of NHS responsibilities. Taken together, this raises a serious question: is the aim to ensure children receive the health services they are entitled to, or to legitimise workarounds that place unmet NHS responsibilities on schools? A way forward If the government is serious about improving outcomes, it must be honest about its intent. Clinical healthcare in education settings cannot keep shifting to schools. The SEND proposals and draft medical conditions guidance do nothing to address the structural gaps and fall short of the policy rhetoric. The joint call from unions for an NHS commissioned clinical nursing service in every school shows what is needed. Delivering this requires political will and transparent, possibly uncomfortable discussion about compliant NHS service models and the investment and workforce needed to deliver them.