Archived decisions
Health of our Children and Young People
Draft Report 30 November 2004
Access to Therapy Services for Children in School and Pre-school
.1.1
Review of access to therapy services for children in school and pre-school
Draft report
1. Summary
1.1 This review was identified by the Health Review Committee as part of a themed focus on the `health of our children and young people'
1.2 Initial concerns arose from a complaint to the Ombudsman in January 2004 regarding the delivery of speech and language therapy to a statemented child who had moved in to the county from another area. Investigations into the complaint highlighted tensions between the responsibilities of education special educational needs services (SEN), the Primary Care Trusts (PCTs) and Speech and Language services.
1.3 The working group has gathered evidence from a wide selection of stakeholders and acknowledge that the issues raised in this review are extremely complex.
1.4 The review was due to feedback to the Health Review Committee in September, however the working group decided to extend the review timetable to allow consideration of the impending National Service Framework for Children.
1.5 The review recommendations acknowledge and reflect national initiatives to bring about more focused and joined up services for children nation-wide.
1.6 The report is divided into the following heading. Click on the heading and you will be taken directly to that section of the report
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2. Scope
2.1 This review commenced in May 2004 with Cllr McNair Scott and the Review Team Leader meeting to draw up the scope and project plan. The working group comprised of:
· Cllr Mrs McNair Scott (Review Chairman)
· Cllr Mrs Dickens
· Cllr Mrs Heron
· Cllr Mrs Holden-Brown
· Cllr Mrs West
· Angela Anderson, Child Health Network
· Marilyn Barton, Strategic Manager, Early Years and Childcare Unit
· Fiona Corkhill, Neonatal and Therapy Services Manager, North Hants Hospital Trust
· Julie Graham, Physiotherapist, North Hants Hospital Trust
· Tom Key, Children's Lead, North Hants PCT
· Maggie MacDonald, Head of Early Education and Childcare Unit
· Felicity McElderry, Paediatric Occupational Therapist, Winchester & Eastleigh Healthcare Trust. NSFC Taskforce member
· Mary North, Speech and Language Therapist, North Hants PCT
· Eric Smith, Education Officer SEN
· Chris Toner, Acting Head of Specialist Teachers Advisory Service
· Cliff Turner, Principal Educational Psychologist
2.2 A full list of stakeholders can be viewed in Appendix 1.
2.3 The review began by focusing on paediatric therapy services for 0-16 year olds (0-19 for young people with learning disabilities in special schools). However as the review progressed the scope was tightened to focus on children who have developmental delays and problems that present as they reach pre-school / primary school age. It was recognised that special needs in 0-3 year olds are often more apparent and therefore more easily identifiable by paediatricians, midwives and health visitors. For other children special needs may not be picked up for the first time until pre-school or primary school as they fail to reach, or are delayed in reaching, normal developmental milestones. Pre-schools have been included as research shows that treatment in the early years can facilitate greatest progress for the child. Consequently early intervention has been identified as a national and local priority
2.4 The diagram below shows that baseline universal services are available for all children (health visitors, pre-school, school). The top section is specialist services for children who are identified as having disabilities at birth; this group are fairly well provided for through therapy services, Portage etc. The middle section represents those children who do not have an identified disability but may not reach developmental milestones or show delays in communication, socialisation, fine motor skills etc. For many of these children attendance at pre-school or reception class could be the first point that developmental concerns are expressed. This change also provided a tighter link to the work being undertaken by the Children's Board who are developing Hampshire's approach to the Children Bill.
Specialist services
Targeted services
2.5 The review aims were:
· To develop a global map of therapy service provision across Hampshire
· To identify local and common issues and concerns for those involved in service delivery
· To agree constructive and achievable goals for short and long term service improvements
2.6 In an attempt to understand the complex nature of therapy services many local issues were identified. To keep the review strategic only those issues that are common to most areas will be included. Other issues will be flagged up if and as appropriate
3. Methodology
3.1 A variety of methods were adopted to inform the review working group. It was apparent from an early stage that the issues surrounding the delivery of therapy service to children were very complex. All three therapy services (speech and language, occupational and physiotherapists) wished to be represented on the review team and therapists in each locality across Hampshire wished to share their concerns and issues. Interviews were held with staff in each locality and with therapy managers centrally. In addition, a questionnaire was designed and distributed by the therapy services representatives to each strand of the service in each locality.
3.2 Due to the strategy of early intervention, interviews were held with Early Years Area SENcos in each of the five areas. This helped pick up issues that pre-school staff may have when needing to refer a child to therapy services
3.3 A questionnaire was also distributed to each primary/infant school through each of the seventy one Foundation Stage cluster leads. This aimed to pick up concerns from the schools over accessibility to and response times from therapy services. The questionnaire also gave an opportunity to comment on issues for parents or children around the process and pick up any training issues.
3.4 Desk research was carried out to examine academic work that had been conducted, search for other local authority reviews on the topic and identify training options.
3.5 Meetings were held with the Strategic Health Authority regarding a planned Child Health Network and Social Services for information on Hampshire's implementation of the Children Bill. The latter will have a role in examining the integration of children's services and both have expressed an interest in the review findings.
3.6 A visit was made to Shepherds Down Special School by the review chairman to view facilities and discuss issues and actual speech and language therapy sessions were observed in a mainstream school.
3.7 The review working group met on two occasions and considered briefing papers and progress reports in between
3.8 The following documents are attached as appendices
· Appendix 1 - Stakeholder involvement
· Appendix 2 - Partnership agreement between therapists and education
· Appendix 3 - Responses from speech and language therapy questionnaire
· Appendix 4 - Responses from occupational therapy questionnaire
· Appendix 5 - Responses from physiotherapy questionnaire
· Appendix 6 - Area SENco issues
· Appendix 7 - Responses from primary/infant school questionnaires
· Appendix 8 - Glossary of terms
4. What are therapy services
4.1 A child has special educational needs if he/she has learning difficulties or disabilities that make it harder for him/her to learn than most other children of the same age or difficulties accessing the curriculum. Some children may have a temporary difficulty with, for example, reading, number work or behaviour which can, with the help of parents/carers, therapists and schools, be overcome. Others may have a disability for which special equipment enables access to the curriculum while for some, strategies may be required to help manage on-going needs.
4.2 Speech and language problems fall into two categories: receptive and expressive. Any child who has difficulty understanding language will also have problems with expression, but some children have good receptive skills while being unable to formulate their thoughts and feelings into spoken language. Some children will be generally delayed, ie their development in all areas will be slower than usual. For others, development occurs at a generally normal pace with the exception of one or more areas of speech and language. The difficulty then is the term `specific language impairment'. Speech and language therapists use a range of standardised tests and norm-referenced checklists, as well as direct and reported observations to assess the child's needs. Speech and language difficulties may be accompanied by behavioural problems due to the frustration caused by communication problems.
4.3 Occupational therapy is concerned with all aspects of a child's life: physical, psychological and social, and takes a holistic view. Children with difficulties such as developmental coordination disorder (DCD) have problems with everyday tasks requiring motor coordination such as handwriting, dressing and learning to ride a bike. DCD can severely limit school performance, self-esteem and age appropriate activities of daily living. The occupational therapist aims to help children become as independent as possible in everyday activities and to reach their maximum functional potential. The occupational therapist analyses the child's functional performance to identify strengths and limitations in a range of physical and social environments. Standardised tests and observational assessment may be needed to examine abilities :
· Coordination
· Sensory and Perceptual Skills
· Self-care eg eating, dressing
· Learning eg handwriting
· Emotional, developmental and behaviour social skills
· Play and leisure eg cooperating with others in rule based games
· Equipment
· Adapt ions
4.4 Physiotherapists work with children who have a general delay, disorder of movement, disability or illness that may be improved, controlled or alleviated by physiotherapeutic skills and/or the use of specialised equipment. The aim of the paediatric physiotherapist is to encourage each child to fully develop his/her potential so that maximum function is achieved, deformity is prevented or reduced and the effect of handicap minimised. During a child's early years the physiotherapist will support problems caused by developmental delay, motor dysfunction and poor coordination and learning difficulties. The physiotherapist works closely with the family to enable the child to the best of his/her ability in order to lead the fullest life possible
5. National Guidance
5.1 There is a great deal of ambiguity regarding the responsibilities of the Local Education Authority (LEA) and National Health Service for the provision of therapy services. Legislation is fraught with `loop holes' and `get outs' which only exacerbate an already complex system
5.2 Section 322 of the Education Act 1996 states that `Health authorities, subject to the reasonableness of the request in the light of the resources available to them, must comply with a request for help by the LEA in connection with children with special educational needs, unless they consider that their help is not necessary for the exercises of the LEA's functions'. The 1997 Green Paper Excellence for All Children: Meeting Special Educational Needs and the subsequent Programme of Action published in October 1998 made a commitment to improving the statutory framework and procedures for SEN, building on experience and best practice. This commitment was taken forward through the Special Educational Needs and Disability Act 2001.
5.3 In November 2001 the DFES released guidance on `Inclusive Schooling: Children with educational needs'. This stated that `Children who have special educational needs but do not have a statement must be educated in a mainstream school'. A growing number of children with special needs are now being mainstreamed; this has caused further issues for the delivery of therapy service.
5.4 The Special Educational Needs Code of Practice became effective from 1 January 2002 and provided practical advice to Local Education Authorities, maintained schools, early education settings and others on carrying out their statutory duties to identify, assess and make provision for children's special educational needs. The Code of Practice notes that
· `Case law has established that speech and language therapy can be regarded as either educational or non-educational provision, or both, depending on the health or developmental history of each child. However since communication is so fundamental in learning and progression, addressing speech and language impairment should normally be recorded as educational provision unless there are exceptional circumstances'.
· `Where the National Health Service does not provide speech and language therapy for a child whose statement specifies such therapy as educational provision, ultimate responsibility for ensuring that the provision is made rests with the LEA, unless the child's parents have made appropriate alternative arrangements'.
· `Meeting the special educational needs of individual children requires flexible working on the part of statutory agencies. They need to communicate and agree policies and protocols that ensure that there is a `seamless' service'.
5.5 However, despite changing legislation and practice the Audit Commission's report Special Educational Needs - a mainstream issue (2002) highlighted a number of continuing challenges
_ Too many children wait for too long to have their therapy needs met
_ Children who should be able to be taught in mainstream settings are sometimes turned away and too many staff feel ill equipped to meet the wide range of pupil needs in today's classrooms
_ Many special schools feel uncertain of their future role
_ Families face unacceptable variations in the level of support available from their school, early years settings or local health service.
5.6 The Government recently launched Removing Barriers to Achievement which sets out the strategy for SEN as promised in the Green Paper Every Child Matters. The strategy aims to personalize learning for all children and make education more responsive to the diverse needs of individual children. It focuses on early intervention, preventative work and integrated services for children through Children's Trusts to deliver real and lasting benefits to children with SEN and their families. It states that `speech and language therapy, occupational therapy and physiotherapy are important in supporting early intervention'
5.7 The Children Bill (2004) sets out new duties which are intended to promote integrated services targeted to ensure improved outcomes for all children
_ new duties to co-operate to improve the well-being of children and young people and to safeguard and promote welfare
_ to establish information databases
_ to establish local safeguarding children boards
_ to appoint directors of children services and lead members for children's services
_ to establish joint area reviews
5.8 The National Service Framework for Children, Young People and Maternity Services (NSFC), came out in September 2004. It sets out a ten-year programme for eleven standards for health and social care that authorities must achieve by 2014. The NSFC aims to promote high quality integrated health and social care services that are child and family centred. Resources are likely to be an issue as there appears to be no significant ring-fenced funding to support overall implementation. The NSFC is broken down into three sections:
_ Part One includes five core standards that apply to all services for children and young people
_ Part Two has five standards that relate to children and parents with particular needs and build on the core standards
_ Part Three is specific to maternity services
5.9 In addressing the issues of therapy services the NSFC specifies that:
· Therapy waits greatly harm educational attainment and wider development
· Local and health authorities must clarify and implement joint and individual responsibilities for providing timely therapy services to meet the needs of children and young people
· Children and families need to be involved in commissioning and service re-design
· It is crucial to provide training for childcare/pre-school/school staff
· Equipment should be available which is tailored to the child's individual needs and future development
· Local Authorities and PCTs ensure the supply of timely therapy services is sufficient to meet addressed needs
5.10 The NSF requires a cultural shift in the way we view children and their services. However, together with the Children Bill and the forthcoming Public Health White Paper, it forms a solid platform on which health services, local authorities and the voluntary sector can work together for the benefit of children and families.
5.10 The National Child Health Service mapping pilot will begin in November 2004. This will be an annual data collection exercise to describe child health provision across England. The first year will establish a baseline and the yearly exercise thereafter will monitor the change of services over time. It is being commissioned and developed through the Department of Health. One of the aims is to collect data on `services to disabled children to include models of therapy services and waiting issues'. First data collection will take place in November 2005 with the first years results published in June 2006. It is hoped that this timing will coincide with the local implementation of key child policy such as the Green Paper, Children Bill and the Children's National Service Framework
5.11 The `National Standards, Local Action', Health and Social Care Standards and Planning Framework (2005-2008) includes children and stresses the statutory duties of partnership established under the '99 Health Act. It states that both the NHS and Local Authorities are required to `work together to achieve the cooperation needed to bring about improvements in health care'.
6.1 In Hampshire the commissioning and distribution of services is complex and it was not an easy task to map where services are delivered from, what the referral processes are or how long a child has to wait to access a therapist. This situation is made more complex as both Portsmouth and Southampton PCTs deliver services for parts of Hampshire. The following diagram illustrates the number of agencies who have some input or influence on therapy services.
Acute trusts
6.2 Delivery of speech and language therapy and physiotherapy is managed by the PCTs. With the exception of Southampton occupational therapy is managed by the NHS Trusts
_ Winchester and Eastleigh Healthcare NHS Trust provides services for Mid Hants PCT and the north of Eastleigh and Test Valley South PCT area
_ Southampton City PCT provides services for the rest of Eastleigh and Test Valley South PCT area plus New Forest PCT.
_ Portsmouth City PCT also covers East Hants PCT and Fareham and Gosport PCT
_ North Hampshire Hospitals NHS Trust provides occupational and physiotherapy for North Hants PCT. The PCT provides it's own speech and language therapists
_ Frimley Park Children's Centre provides for Blackwater Valley and Hart PCT.
_ Salisbury Healthcare Trust provide services in the Ringwood and Fordingbridge areas of the New Forest for South Wiltshire PCT
6.3 Children needing to access a therapist may attend a hospital clinic, a health centre, see a therapist in school or their own home. There is no set model that describes how this should happen, neither is there any guidance produced by either Health or Education to explain the process to the parent and child and advise them what to expect.
6.4 Funding for these services has not been a priority as there are no national targets that need to be met. The NSFC may change this situation but the large financial deficit across the health economy in Hampshire will make this difficult without re-prioritisation. The PCTs believe that there needs to be greater joint provision through
_ Joint funding
· Workforce management
· Professional development
· Integration
· Joint service development
· Outcome measurements / care pathways
· Equipment
· Border planning
6.5 Each PCT has a Children's Lead and there is potential for these officers to take a stronger role in planning and monitoring therapy services.
6.6 Hampshire has three SEN Education Officers who work with schools on a patch system. The Education Department believes that all therapy provision is a health service responsibility as the LEA is only responsible for the educational needs of the child. Education recognises that there is a need for more joint planning of services.
6.7 Speech and language therapy provision can be considered in law as either educational or non-educational. If it is specified in the child's statement as educational provision, the Council has a duty to ensure that it is supplied. If the therapy service is to be provided by a health authority, the failure of the health authority to make the necessary provision does not relieve the Council of the duty to provide it. Occupational therapy is sometimes seen as an `educational need', physiotherapy is not.
6.8 In his 2004 report the Ombudsman reminds the County Council that `they have a legal duty to arrange that the special educational provision specified in the statement is made unless the parent has made suitable arrangements'.
6.9 In March 2003 the LEA calculated that it provided in excess of £4.3m for additional provision for children with statements of SEN for whom language or communication difficulties were a prime need.
6.10 The LEA works closely with the Hampshire Portage Service which provides an educational home visiting service to 250 children across Hampshire. Children accepted to receive support from the service have delays in two areas of development of at least a third of their chronological age, or a recognised syndrome or diagnosis which is likely to lead to significant delay. A trained Portage home visitor visits the family on a regular basis, usually weekly, and activities are left that the parent/carer can carry out with their child to encourage their development.
6.11 Portage home visitors work collaboratively with other agencies to ensure that advice and practice is consistent and the most appropriate for the individual child. The Portage service encourages pre-schools to play a more proactive role in supporting children with developmental delays. Training is a key issue. It was suggested a problem-solving framework be developed by the professionals for use by early years SENcos. In addition it was noted that variation in referral systems complicate the process and need to be standardised. Again access to appropriate equipment was identified as a problem. Therapists have identified the need for more support and closer working with Portage.
6.12 The LEA has an established SEN county group where speech and language managers and education officers meet twice a year. Several years ago the group drew up a partnership agreement as a model of good practice (Appendix 2) The therapists feel that this group is not working effectively and the partnership agreement does not fully represent recent changes. For example there is no mention of early intervention and pre-school involvement.
6.13 The educational psychology service deals with children who have social, emotional and behavioural difficulties. Although EP's do not provide a direct therapy service to children there is a knock-on effect for them through children being unable to access the therapy they need to overcome their developmental delay. For example, boys (generally) do not develop the fine motor skills needed for handwriting until they are around the age of five/six years. If the teacher has concerns and refers the child for an assessment by an occupational therapist the child could wait up to two years for an appointment. During this period the child may find it increasingly difficult to keep up with classroom and curriculum activities, become bored and easily distracted. This increases the likelihood of behavioural problems so the child may also need referring to an EP. This example shows the importance of providing a seamless range of services that are based around the child's need rather than be constrained by departmental and organisational boundaries. It has been suggested that there is scope for the EP and therapy services to work closer however the EP service has a shortage of trained EPs to work directly with children (only 108 trained per year country-wide). They also would like to recruit assistants who could be trained to work with children.
6.14 EPs have also noted that investment in early years is essential to minimise problems later and that there is a lack of communication between agencies. A national database and ID system could enable more efficient tracking of individual children/families. This would allow professional agencies to share information that is critical to their role and the child's needs.
6.15 The Early Education and Childcare Unit is responsible for delivering the governments Child Care Strategy in Hampshire. As part of their SEN strategy they promote inclusion of children with special needs in early years settings, employ area SENcos and provide training. The Unit is also responsible for establishing a series of children's centres as part of a Local Preventative Strategy to develop integrated services across Hampshire. The children's centres would be obvious bases for therapy services, if space were available.
6.16 A proposal is being developed for the Early Education and Childcare Unit is to fund a new loan scheme to provide special needs equipment to enable children to attend pre-school. This is a recognised gap as education provide equipment for schools, Social Service for home and the health trusts provide a small budget for incidentals eg cutlery.
6.17 In responding to the Children Bill, Hampshire County Council has established a multi-agency Children's Services Board to identify strategic objectives and to oversee progress in implementing integrated services at a local level. In April 2005 a sub-group of the Board will begin planning what an integrated approach will look like in Hampshire. The board project manager would like the review findings to inform this group.
6.18 The Strategic Health Authority (SHA) has supported the development of a Child Health Network for Hampshire and Isle of Wight. Its board includes representation from clinicians from Acute Trusts and PCTs, SHA, commissioning, Children and Adolescent Mental Health Service (CAMHS), Workforce Development Confederation, specialist commissioning and Public Health. It is planned to have parent and carer, nursing and therapy representation in the future. The Child Health Network is particularly interested in this review and findings. The SHA has a Children's Lead, however it does not maintain an overview of therapy services in Hampshire
6.19 A lot of information was gathered for this review through the questionnaires, interviews and research. In order to get a full picture of access to therapy services for children in school and pre-school each of the following sections will focus on a particular strand of the service. Details of speech and language, occupational and physiotherapy will show what is happening across the county, a section will follow this on early years issues and then the school experience. The therapists were all keen to ensure that data on staffing should not be taken out of context. What may be interpreted as a high staff levels in one area may be due to the high number of complex special needs caseloads.
6 Speech and language therapy
6.1 Responses were received from Blackwater Valley & Hart, North Hants, Mid Hants, Southampton and Portsmouth PCTs, plus Salisbury Healthcare Trust. The full table of responses can be viewed in Appendix 3, the rest of this section picks out key points.
6.2 Services are based in a variety of settings - PCTs, integrated trusts and acute trusts. North Hants is the only PCT to provide its own speech and language service; the rest commission services from the trusts.
6.3 Liaison with education for therapists is difficult in many parts of the county due to border overlaps with Surrey, Southampton, Wiltshire and Portsmouth. Therapists state that where services are provided to more than one LEA the aim is to deliver an equitable service.
6.4 It is difficult to get an overall idea of staffing levels as those PCTs providing to more than one area give combined staffing figures. However it is worth noting that the PCTs provide the majority of funding for staff. A few part-time places have provided through funding from other sources ie Sure Start, Standards Fund. Education funding is provided to support speech and language therapists for specific posts and projects in schools. North Hants and Winchester both reported administration support as being in-sufficient.
6.5 The service is delivered in a variety of settings from a clinic to a child's home. Therapists have a percentage of their time allocated to working with children in special schools. A consequence of the inclusion agenda is that therapists now spend more time travelling to different schools to see children. An additional problem is that many schools that have included a child with significant special needs do not have an appropriate environment for the therapist to work in with the child.
6.6 Client groups for which there are gaps in services in Hampshire include:
· Looked after children
· Children with emotional and behavioural disorders
· Children over 16
· Secondary school children
· Children with ASD
· Specialist stammering service
· School age children without statements
· Children with moderate learning difficulty
6.7 Waiting times for urgent referrals varied. Blackwater Valley and Hart, North Hants and Portsmouth all stated they would see the child within four weeks; Southampton and Winchester said between 6 and 12 weeks. Waiting times for non-urgent covered a greater time span with only Portsmouth stating 0-6 weeks, Southampton 6-12 weeks and North Hants, Winchester and Blackwater Valley and Hart all falling in the 3-6 month category. Once an assessment had taken place only Winchester reported that there was no waiting list for treatment.
7.8 All PCTs reported providing some training to both SENcos and learning support assistants. Topics covered included communication difficulties, narrative therapy, language impairment, language development, role of speech and language therapists and `I Can' courses for pre-school workers.
7.9 The speech and language therapists identified the following issues as barriers to service delivery:
_ Impact of inclusion
_ Rising expectations of users
_ Demand and capacity
_ Lack of resources
_ Accommodation for therapy
_ Protocol of therapy services working within education
_ Cultural / Philosophical differences
7.10 Therapists from all strands mentioned that there is a significant growth in the number of children with developmental delays due to increases in premature baby survival rates.
7.11 Speech and language therapists stated that they managed to keep the waiting time fairly short by spreading themselves thinly. A child would be assessed, a programme designed and, in most cases, the learning support assistant would include the programme in the child's day to day work at school. The therapist may not see that child for a further year unless there are additional concerns.
8. Occupational Therapy
8.1 Responses were received from Blackwater Valley and Hart, Salisbury, North Hants, Southampton, Mid Hants and Portsmouth PCTs. The full table of responses can be viewed in Appendix 4, the rest of this section picks out key points.
8.2 Delivery of occupational therapy is equally split between the PCTs and acute trusts. The majority of posts have been funded by the NHS Trusts with some recent funding from PCTs. All report that administration support is insufficient
8.4 Client groups which occupational therapy is not able to provide a service to are:
_ Children with emotional disorders
_ Looked after children
_ Children with moderate learning difficulties
_ Children with autistic spectrum disorder
_ Children with emotional behaviour disorder
_ Secondary school children (in mainstream or with special needs other than complex physical disabilities)
_ Young people in transition from school to college or work
8.5 All services reported providing some training to both SENcos and learning support assistants. Topics covered included developmental co-ordination disorder, dyspraxia, handwriting, sensory modulation, gross and fine motor development.
8.6 All services stated that waiting times for urgent referrals would be between 0-4 weeks. For routine referrals only Southampton stated they would see a child within three months however this is because the service has closed its waiting list and is only addressing the backlog of children waiting. Portsmouth and Blackwater Valley and Hart PCTs thought between 3-6 and 9-12 months dependent on priority, North Hants, Mid Hants 12-15 months and Eastleigh Test Valley and Salisbury up to 2 years. Only North Hants stated that following assessment there would be a waiting time for treatment.
8.7 The occupational therapists identified the following as barriers to service delivery:
_ Staffing levels and lack of student practice availability. The service needs more training posts, therapy assistants and administration support to relieve pressure on therapists
_ Many professionals making referrals do not understand the role of the therapist and how the referral system can work best. Portsmouth reported that some GPs and school doctors make inappropriate referrals thereby increasing demand on services. The PCT used to run awareness raising sessions for GPs which were very successful, the problem has increased since the sessions ceased. A clear framework for referral with a check list to work through when concerns are first raised would be helpful This could be supported by expanding existing training for Learning Support Assistants so they can carry out simple programmes eg handwriting
_ Huge increase in demand with no money for PCT to fund, largely driven by inclusion and greater awareness of need in mainstream settings
_ New initiatives which impact on our service with no funding eg Education CAMHS, Sure Start, Connexions, Portage expansion.
_ Service has to be continually reviewed and restricted to priority client groups - not equitable for all children
_ No treatment room provided by education in special or mainstream schools
_ Concerns over transition from secondary school to FE education or the workplace
_ Funding for equipment for children
_ Poor communication
_ Impact of Disability legislation (SENDA) and access strategies - education settings needing specialist advice
8.8 Occupational therapist report that most referrals are made by year one and two mainstream school teachers. There is a ratio of approximately 10:1 boys to girls being referred for developmental co-ordination disorder. Concern was also expressed on how therapy needs follow fostered or adopted children.
9. Physiotherapy
9.1 Responses were received from Blackwater Valley & Hart, North Hants and Southampton PCTs. The full table of responses can be viewed in Appendix 5, the rest of this section picks out key points.
9.2 The most regular places for service delivery were cited as
_ Out patient clinics
_ Playgroups / nurseries
_ Specialist pre-school units
_ Special schools
_ Mainstream schools
_ Patients' homes
9.3 Staffing levels are fairly consistent across the three PCTs with Blackwater Valley and Hart having a higher assistant level. Two reported that administration support was insufficient
9.4 Client groups for which there are gaps in service in Hampshire include:
_ Children with emotional and behavioural problems
_ Children over the age of 16
_ Children with arthritis, obesity or HIV
9.5 All stated that waiting time for urgent referrals was between 0-4 weeks and for routine referrals North Hants stated between 6-12 weeks, Blackwater Valley & Hart 6-9 months and Southampton between 1-2 years. There were no waiting times for treatment after referral.
9.6 All PCTs reported providing training to SENcos and learning support assistants. Topics covered included postural management, manual handling physiotherapy programmes and developmental co-ordination disorders.
9.7 The physiotherapists identified the following issues as barriers to service delivery:
_ Lack of treatment space in locality areas
_ Lack of IT support
_ Lack of knowledge base of learning support assistants working with children who have disabilities - no formalised training
_ No equipment and no increase in funding for equipment for past three years. Funding for equipment in Hampshire is significantly lower than in Surrey. An audit of equipment and resources in circulation would be useful
_ Lack of funding to match growing demand due to the inclusion agenda
_ No service for direct GP referrals
_ Poor communication between agencies
_ Increasing need for support to children with respiratory difficulties
9.8 The physiotherapists felt that specialist structured training was needed for learning support assistants and teachers to raise awareness of a) therapists work, role and referral system, b) what programmes are safe to do with the child, c) where to go for further information, d) the importance of the child's individual education plan and therapy plan and e) parent/home link. A training post could meet all these needs.
10 Early Years SENcos
10.1 The Early Education and Childcare Unit employ seventeen area SENcos based at five locations across the county in Basingstoke, Aldershot, Totton, Waterlooville and Eastleigh. Their role is to provide advise and support for setting SENcos on implementing the Code of Practice, run induction training and liaise with outside agencies to monitor individual children and problem solve. Each pre-school setting has a named SENco.
10.2 Interviews were held in each locality to develop an understanding of relationships and issues for area and setting SENcos dealing with therapy services. Despite local differences many common themes emerged which need to be recognised and addressed by the working group. A table of area SENco issues can be viewed in Appendix 6
10.3 The main issues identified by the area SENcos are:
_ That early years settings are virtually never included in assessment and treatment of children. It is usually only possible for the setting to access information on the child's treatment through the parent and most parents are not aware that their permission is required or know how to go about giving it. Pre-school settings are not, therefore, able to play an informed and constructive role in supporting the parent and helping the child to overcome their delays or difficulties. Once the child reaches school age this situation changes as assessment and treatment is delivered in the school with the parent and learning support assistant involved. This involvement provides continuity of approaches for the child by those providing everyday care. This practice needs to be extended to pre-school years.
_ The need for contact with speech and language and occupational therapy were perceived as more immediate than physiotherapy. This was partly to do with children who need physiotherapy having an established programme of treatment, therefore there was less need for new referrals. However setting SENcos wanted better liaison with physiotherapists on integrating children with significant special needs into the pre-school.
_ Accessing equipment for children with physical difficulties to use in pre-school was a common problem in all areas.
_ Setting SENcos appeared to be more readily able to access speech and language therapists than occupational therapists with several areas reporting that it was impossible to make a successful referral for pre-school age children. The levels of occupational therapy access reflect the resourcing shortage.
_ The variation in waiting times for assessment and treatment was marked. For speech and language therapy this was between 6 weeks and 12 months. For OT between 3 months to not worth even asking for appointment.
_ Referral routes also varied greatly with area SENcos in the same locality having different referral systems depending on the PCT commissioning the service or individual preferences of key staff
_ The area SENcos endorsed the therapists concerns regarding confusion over roles and responsibilities
_ All area SENcos reported that the transition process from pre-school to school worked well and that passing on information regarding a child's programme would not be an additional burden.
10.4 It should be noted that there were some discrepancies between waiting times as stated by the therapy services and waiting times as experienced by early years settings.
11. Primary / infant Schools
11.1 In order to get a fuller understanding of access to therapy services in schools a questionnaire was sent to each primary/infant school in Hampshire. The questionnaire set out to establish a benchmark of how many referrals were made for each strand of therapy services in the year 2003/04, what waiting times were, training needs and issues for parents and children. Appendix 7 shows the collated responses.
11.2 The response rate was disappointingly low but, perhaps due to the short deadline, this was to be anticipated. However the questionnaires have provided both quantitative and qualitative information which does mirror the general trends already identified.
11.3 Twenty nine responses were received from schools in each area of the county. Several responses were from special schools or schools with language impairment units. As might be expected, there was a noticeable difference in ease of access to therapy services to that experienced by mainstream schools.
11.4 Speech and language was the service most childr4e were referred to during 2003-04 with seventeen schools referring between 1-3 children and two schools referring over 7 children. Occupational therapy was next with ten schools referring 1-3 children and physiotherapy received only two referrals. Both occupational and physiotherapy received comments on the difficulty of accessing their services.
11.5 Waiting times for speech and language assessment reflect times stated by the therapists. At first glance occupational therapy times seem very low but comments show that many of the referred children are still waiting for assessment or there is no therapist available. Once assessed the majority of children did not have to wait more treatment.
11.6 All respondents reported that the school was involved in the delivery of the child's programme. Some schools reported difficulties in delivering the programme due to other demands on staff time.
11.7 The majority of schools felt that the child's needs were being met through the delivery of programmes in school. Although a plea for more speech and language time was made.
11.8 The main issues for parents were identified as
· Long wait for initial assessment (7 comments)
· Not being kept informed of their child's progress (4 comments)
· Parents being unsure of their role (3 comments)
· Difficulty in getting direct access to therapy services (3 comments)
11.9 The overarching view for children was that they enjoyed working with the therapists but being withdrawn from class and continuity of therapist were identified as concerns.
11.10 Just over half the respondents felt that they had received adequate training to support the child's programme. The remainder felt they would benefit from receiving more specific training on programme support. The following were mentioned as potential topics:
11.11 Whilst acknowledging good support from the therapists the schools also comment on problems due to long waiting times, insufficient contact and problems due to staff changes. Interestingly several schools noted that more should be done to identify problems at the pre-school stage and that the EP service should also be reviewed to improve access for children with learning difficulties.
12 Research
12.1 A group of researchers have produced a series of reports over the three years looking at the provision of speech and language therapy services for children in England and Wales. A particularly relevant paper is entitled `Collaboration between LEA and SLT managers for the planning of services to children with speech and language needs (2003)' and examines data from 15 different authorities. The article recognises that `considerably more is known about the barriers to collaboration than the factors that promote and sustain effective practices'. Boundaries, funding sources and the lack of distinction between educational and non-educational therapy are all identified as major difficulties.
12.2 A key aim of the study was to identify factors that were thought to promote and sustain effective collaboration between LEAs and their corresponding Trust partners. These are:
_ That structures be put in place that enable joint strategic planning across Trusts and LEA
_ That national and local mechanisms be put in place to monitor the level of collaboration and disseminate effective collaboration
_ That LEAs act as lead commissioners through local NHS providers of speech and language therapy services for children in educational contexts
_ That there be a comprehensive accredited system of educational and training opportunities for all staff working with children with speech and language needs
12.3 The National Association of Paediatric Occupational Therapists recently produced a report `Doubly Disadvantaged' covering a national survey of waiting lists and waiting times for occupational therapy. In the report they cite evidence that children with developmental coordination disorder (DCD) do not `grow out of it'. Eighty percent of 22 year olds with DCD had poor psychosocial outcomes compared with thirteen percent in a comparison group without DCD. Poor outcomes included being unemployed, having broken the law, being an alcohol or drug misuser, or having mental health difficulties. The prevalence of DCD is five percent of the childhood population'. Long waiting times also have a serious educational impact on these children.
13 Conclusions
13.1 The availability of therapy services to children in school and pre-school across Hampshire is inconsistent, lacking in strategic leadership and carries unacceptable waiting times. No one organisation or partnership maintains an overview and many children receive no service at all.
13.2 All children should receive timely therapy support and treatment in order to overcome their development delay or disability and reach their full potential. Research shows that developmental disorders, if left untreated, can lead to behavioural, emotional and mental problems in both childhood and adulthood. It is the responsibility of all working in health and the local authority to ensure that this does not happen
13.3 There is a lot of quality, innovative and caring work being carried out by staff who are passionate about their desire to help children overcome their difficulties. However lack of strategic direction means that relevant agencies are not working together to share responsibilities efficiently.
13.4 New national expectations and responsibilities provide a unique opportunity for the Strategic Health Authority, Local Education Authority and the PCTs to move toward interagency working. A joint planning group would need to examine existing services and produces new strategic guidelines for improvement and standardisation of future service delivery across Hampshire. Border issues with other authorities can then be dealt with from a position of strength and clarity.
13.5 Disagreement over what is non-educational or educational provision is not helpful. All agencies should contribute to drawing up a clear set of criteria for a Hampshire based framework. The existing partnership agreement may be a good starting point for discussion.
13.6 Adequate and consistent therapist staffing levels need to be made and maintained. Service commissioners should work together to establish local needs and then develop the infrastructure to meet those needs. Lack of NSFC funding and local financial constraints are recognised, however there is the desire amongst staff to be creative and innovative to identify potential new ways of working. This may mean pump priming rather than long term funding. Therapy assistants and trainers may be one such way.
13.7 Therapy services should, ideally, be delivered in an environment that children are familiar with and comfortable in. Local community bases should be identified to facilitate this. Consideration of the potential of children's centres, early years centres and extended schools should be explored. Accommodation for assessment and treatment needs to reflect this purpose.
13.8 Improvement in communications at all levels is needed. Different systems operate both between and within localities, this exacerbates an already complicated system.
· Professionals in many areas expressed confusion over roles and responsibilities of colleagues in other services
· Little or no information is provided for parents and children in advance of the process and what to expect.
· There needs to be a standardised referral system with clear information available to all professionals working with children on the process
· A common, shared language for all professionals
13.9 Despite early intervention being identified as a priority few early years settings are included in the child's programme. Existing systems for assessment should be universally available to ensure that the child's keyworker or SENco are included in the assessment process and are able to support the child and its parent with the programme implementation. This will provide a joined up approach for the child from an early age and strengthen the transition process with the school. In addition an early years equipment and resource bank needs to be established, ideally with an on-line itinerary and application process. This will improve the availability of special needs equipment to help children in pre-school settings.
13.10 Training and development programmes need widening. Many staff felt they would like additional basic information on how to support a child with its programme. SENcos wanted more in depth information on wider range of topics. Consideration should be given to the common assessment framework currently being developed by the DfES and DoH to support all staff in health, social care and education working with children.
13.11 It is interesting and perhaps not surprising that the issues raised through this review strongly reflect the recommendations and Markers of Good Practice outlined in the National Service Framework for Children. Recommendations from the Framework and the Children Bill must be seen as the goals to be aimed for by the Local Authority and Health Services in Hampshire .
14 Recommendations
14.1 It is acknowledged that the Health Review Committee has no power to insist that other agencies take responsibility for review recommendations. However the findings and conclusion for this review highlight the need for strategic partnership and direction in Hampshire that echoes changes and challenges being set by Central Government.
14.2 The Health Review committee would like to invite responses to the findings and conclusion of this review from:
· Chief Executives of Hampshire Primary Care Trusts
· Hampshire County Council Education Department
· Hampshire and Isle of Wight Strategic Health Authority
· Hampshire County Council Children's Services Board
· Hampshire and Isle of Wight Child Health Network
It would be helpful if in your response you identify steps that can be taken to address the issues listed:
· Strategic direction
· Equity of services
· Waiting times
· Partnership working
· Criteria for assessment
· Staffing levels
· Increased community bases
· Communication
· Pre-school partnership
· Training and professional development
14.3 In you feel unable to address any of the above issues please could you inform the Health Review Committee of the reasons in your response.