Welcome to our evidence session of the Education Select Committee, which is part of our inquiry on special educational needs and disabilities called “Solving the SEND Crisis”. I welcome Members and witnesses this morning. I particularly welcome Anna Dixon, who is guesting with us this morning from the Public Accounts Committee. I will invite witnesses now to introduce yourselves to us, starting with Janet Harrison.

Hello, everybody. I am Janet Harrison. I am a speech and language therapist. I am here representing the Royal College of Speech and Language Therapists today. I am Head of Service at Leicestershire Partnership Trust for Children and People’s Services, and I am also leading some work on the SEND and Alternative Provision Change Programme across Leicester, Leicestershire and Rutland.

I am Lisa O’Connor. I am Vice-President of the Association of Educational Psychologists. I am also an educational psychologist who works in a local authority service. I do not know if you want me to explain what educational psychologists are.

Yes, please.

They are specialist individuals, very skilled professionals who have specialist training in human development, mental health, learning and education systems. They combine psychology, education and counselling and use psychological theories and evidence-based strategies to support children with additional needs, behaviour challenges and mental health concerns.

Good morning. My name is Professor Ian Kessler. I am Professor of Public Policy and Management at King’s Business School, and I am also Associate Director of the Health and Social Care Workforce Research Unit, both at King’s College London. I am here mainly in the latter capacity. The Health and Social Care Workforce Unit is one of about a dozen policy research units that are funded by the Department of Health and Social Care. One of the projects they commissioned us to undertake about 18 months ago was to review the demand and supply of NHS therapists for children and young people with SEND. We produced a report, which we published in early 2024, which explored those issues.

Thank you very much. We have heard already on our inquiry a lot of evidence that there are shortages across educational psychology and allied health professionals. Could you tell us what specific impacts those shortages are having on the diagnostic pathways and access to support for children and young people with special educational needs and disabilities?

We would reframe what you have mentioned, in terms of thinking about the role of educational psychologists, in identifying needs and then supporting those individuals, parents, carers, families and education staff to be able to address those needs, to be able to support them with the appropriate interventions and provision.

The question was about the shortage. We have had a lot of evidence that there is a shortage of educational psychologists. We know that children are often waiting a very long time to be seen by an educational psychologist and that that appointment is critical to identifying what support should be provided for that child and to unlocking that support. It is the shortage that I was asking about, if you could comment on that.

There have been some very major changes to local authority budgets, which have impacted on the capacity and delivery of EP services. A reduction in local authority funding is part of the austerity programme and with the growth of academies who receive funding directly from central government there was a reduction in local authority education budgets. There were also changes in the way in which schools were funded, which has affected local authority services. Also, this has led local authorities to reduce considerably their EP services, with many of them only employing EPs to carry out statutory duties.

Can you tell us a bit more about that? Are there enough EPs working in local authorities? On that point about what role they are undertaking at the moment, how has that changed from—if we think back 10, 15 years, what would an EP service within a local authority look like and what does it look like now?

One of the big issues is, due to the capacity of EP services, we cannot do as much work in early years as we used to be able to do. When we think back 15 years or so, we would have been working with the Every Child Matters framework and working with other publicly-funded services, health services and education specialist services, and we would be working together collaboratively and promoting inclusive practices. That is one of the areas where there is a considerable difference these days. We are in a position where we have not got the capacity to do as much early years work as we would like to, and it is very much missed.

I am sorry to be labouring this point about the numbers of educational psychologists, but it is something that we want to get to the bottom of because we hear a lot from parents, from local authorities, from other professionals, that there are not enough. Yet it also seems to be the case that if a family has the capacity to pay for a diagnosis for an appointment with an educational psychologist, then that is available. If one of our recommendations was to be there should be more funding to train more educational psychologists, that is a significant thing to ask of the Government. What we are keen to understand is: is there a total shortage of educational psychologists that would demand that more educational psychologists are urgently trained? Or is it the case that the shortage is specifically educational psychologists working in the public sector, and that if the Government were to change the incentives, the way that the funding and the job role works within the public sector, there would be enough educational psychologists if we could just get them back into the sector? I hope you can understand why this question matters to us as a Committee, and I would welcome your thoughts on it.

Certainly I think that the pay has decreased. I think the quote is about 17% in real terms over the last 10 to 12 years, so that has made a difference. The positioning and commissioning of educational psychologists has led to market forces, so there are people who work now in the private sector as opposed to working for the publicly funded services.

Thank you, that is helpful.

In terms of speech and language therapists, the Royal College would want to flag a number of different issues affecting speech and language therapists working within this sector. Most speech and language therapists working with children and young people have inordinately large caseloads. I manage a speech and language therapy service myself in Leicester, Leicestershire and Rutland. I would say throughout my whole career speech-language therapists have had extraordinary large numbers of people to deal with on their caseloads. What it leads to is a dilution of the access, the speed of access, the responsiveness. It leads to dilution of intervention. We always have a mind on trying to move children through that system so that we can get into other numbers. It feels a very numbers-driven professional life to be part of. There is a consequence of increased dissatisfaction from families. We spend a lot of time dealing with complaints about waiting times from distressed families, and we completely understand and appreciate the circumstances that they are in. It has an adverse effect on the health and wellbeing of speech and language therapists. I have watched moral injury play out for years with people who came into the profession to do a good job and to do a comprehensive piece of work with children and families such that their outcomes could be improved. Job satisfaction and its deterioration has led to lots of people leaving. The Royal College latest vacancy survey stands at 19% of speech and language therapy posts across England, in both the NHS and the independent sector. I am in the position in my local service where we do not have any vacancies and we have to work so hard to try to keep ourselves fully staffed. I would say that within that profile of staffing I have lots of concerns about the health and wellbeing of the staff. Particularly newly qualified therapists, who we want to stimulate to be excited to be part of the profession, leave quite early. They did not come into it to deal with those larger numbers. I just want to make the point, even when we are fully staffed, the workforce is still massively insufficient in relation to the demand. Another couple of points on that in terms of impact on diagnosis and support, it means that there is a massive mismatch between the resource and the demand for children waiting for diagnosis and appropriate support, and that is evident in the waiting time data collected centrally by NHS England. The figures on the waiting times do not show the full picture. What is reported nationally is access to service, so for the first appointment—I do not know whether you have heard it in other evidence that you have received—we have always fulfilled our target locally and lots of services across England do this for that first assessment. But once you have identified that child needs that support as part of their SEND support, they are then awaiting long periods of time to receive the intervention that they need. As the demand continues to rise, another impact on that is that lots of services across England—we know, as a Royal College—have been commissioned then to work only with children with education, health and care plans, which then generates a whole industry of therapists having to write reports and advice, taking time away from intervention.

The research that we did mainly focused on occupational therapists, physiotherapists and speech and language therapists, and the shortages do vary between those professions. They are particularly acute, we know, among speech and language therapists. But they also vary by region and different parts of the country. Clearly echoing a lot of what Janet said, there is an issue about how shortages are accentuated and deepened, given the nature of the needs that are coming through. We picked up, in particular, that therapists generally in the NHS were having to deal with cases that were much more complex. It was not just a question of numbers. It was a question of the complexity of the cases that they were dealing with. Complexity takes a number of forms. There is a socioeconomic complexity whereby the special educational needs and disabilities are intertwined with broader social and economic deprivation. There are clinical complexities where children are coming through with multiple clinical needs to be dealt with. Then there are administrative complexities around the system and the way it is operating. The waiting times are clearly the basic indicator that NHS England collects, although they collect waiting time by therapy for children and young people teams, not specifically for SEND teams. Most of those children will have SEND needs, but those figures are slightly broader than that. It is an issue in terms of consequence; obviously the distinction between those children with SEND needs and those with education and health plans. Clearly, the consequences for those children are different. Given the statutory requirements around education and healthcare plans, a lot of resource is sucked in to meeting their statutory responsibilities. Where there are staff they concentrate on the statutory responsibilities. Those children with SEND needs may get less access to services or more of a universal type of service than any specialist services.

Just to bring together some of the responses from Professor Kessler and Janet Harrison on this rising demand, I want to get under the surface of that. To what extent is that a hangover from covid and the period of the pandemic? Or is this about a combination of that and structural factors because we saw the living standards go down for the first time ever in any Parliament, in the last Parliament? The final element is an increase in conditions because of perhaps unknown environmental factors that are leading to a rise for whatever reason. It would be useful if you could talk to that and the role of each of those factors in that increasing demand.

I am not a therapist or clinician; Janet might have more of an insight. Our research is based on interviews with around 50 therapists and different leads. My view is it is a combination of covid and longer-term structural factors. It seems to me, from the sidelines a bit, that covid had two effects in generating need. One is it deepened and exacerbated the problems of children who already had special educational needs and disabilities, given the circumstances of covid, living at home, lack of social interaction, and so on. But it also generated new needs among children who may not have had those in the past. But my view, again from the sidelines, would be that there were longer-term structural factors that contributed to increasing need. For example, medical advances, which have been going on for many, many years, meaning that children and young people can survive and thrive with disabilities. Those developments well predate covid, and I suspect that some of the shortages and staff also predate covid as well. That is my layman’s perspective on it.

In answer to your question, the data that we have been collecting for speech and language therapy referrals, for example, and also requests for educational health and care plan needs that come to the whole service, not just speech and language therapy, have shown increases year on year since at least 2006, 2007—huge increases—and that has been consistent. What covid did was exacerbated an already massively growing trend, largely borne out of, I think, from my own experience, managed and local health visiting services. Our healthy child programme delivery was getting stronger and stronger. We were getting good at joint working, good at early identification, early year settings. Particularly as Lisa referred to, our early year setting and early identification approach is strong. What covid did, we had a huge increase in 2019-20. I looked at the numbers and thought, “I do not know how we are going to manage to deal with this great number of children.” Then in 2020 we had obviously a much lower number of referrals. In 2021-22, we saw a huge increase, the same the following year, and this year it started to taper off. That is a local thing, that is not a Royal College thing. The high prevalence of speech, language and communication needs as the most commonly occurring special educational need has been high for a long time. Demand has outstripped supply for a long time. We have been able to respond to that. Covid was an exacerbating feature for what looks like, in our local experience, a pattern of a number of years. One of the consequences though of those numbers and the covid effect, and certainly through the last 10 years, has been the diminishing of universal and targeted support. What has happened is over time, as Sure Start changed and less therapists and less professionals—and Lisa was giving some examples—were able to work in early years settings, being responsive to need in the setting rather than needing a referral for everything, we have a vortex of everything getting sucked into the direction of a specialist service because there is an absence of universal and targeted support available. My recent experience of working as part of the SEND and AP Change Programme through LSEC has started to change some of that for us locally. I think in answer to your question, there is something about digital technology and early interaction that we need to understand lots more about. We definitely see that presenting within some of our early work with families, a reliance on some digital means with which to communicate with children. But I would say that it was a very high referral rate before covid. We did not think it could get any higher and then it did the year after covid, but it has started to see some change for us. Actually, 35% of the children referred to us do not need specialist speech and language therapy. They need good universal and targeted support with the contribution of speech and language therapy in that context.

To continue on the theme, my questions are for Janet and Lisa. What changes could be made to increase the capacity and retention of educational psychologists and speech and language therapists to provide direct support to education settings or to children and young people with SEND? What roles do the DfE and the Department of Health and Social Care have in this?

One of the things that would be very helpful is to have an increase in the number of educational psychologists who are being trained. We know that there is funding for cohorts for 2025 and 2026, but we are not sure about what funding arrangements will be made for anything further. One of the things that we would like to see is a call for a national workforce strategy with regard to the specialists who work in the field of education. Picking up on what Janet said about universal, targeted and specialist, in the past we have been able, with increased capacity, to deliver training and to be able to work with those settings to help enhance their universal support, which has allowed things then to be addressed at a much earlier stage and the needs do not become significant. We would certainly want to safeguard future training and increase the workforce, and have a national workforce strategy. Some work that has been done by the University of Manchester has estimated that we would need to double the number of educational psychologists to meet the needs at the moment.

In terms of speech and language therapy, I think the Royal College of Speech and Language Therapists would echo what Lisa said in regard to educational psychology. Increase the number of speech and language therapy posts through improved commissioning and focus on speech and language communication and outcomes for children. We would want to recommend that DfE and the Department of Health and Social Care work together to develop a workforce plan for SEND. A lot of the work we do as speech and language therapists is in relation to DfE because we are working closely with schools and settings. Then our commissioning obviously comes through a Department of Health and Social Care route, so definitely a workforce plan that considers children and young people with SEND across health, education and social care in an integrated fashion that is not done in silos and separately, because it does not seem to speak to each other. Department of Health and Social Care should collaborate with Royal College on a refreshed workforce plan. We have lots of information about modelling and delivery based on current demand and data and information about current demand and prevalence of this need in the population. I would just like to touch on apprenticeships. We have positive enthusiasm nationally for speech and language therapy apprenticeships. We have way more people in our own service, people who are working as support workers who want to train to be speech and language therapists, but we cannot afford to pay out of our budgets their backfill. For example, this year I have a number of people who want to do that: we put one person forward because that is what we can afford within that budget. In respect of student placements, placement tariffs come in directly to services rather than going to organisations to incentivise services to take a good, healthy number of students on placement to give them a valuable experience. Reducing caseload sizes would help hugely.

The Committee has received evidence indicating that the statutory role of educational psychologists in the education and healthcare needs assessment process could be removed or revised to allow more time and increase capacity for direct support to education settings or to children and young people with SEND. Do you agree with this proposal?

Educational psychologists provide holistic psychological assessments, which are very key for ensuring that the needs of the children and young people are correctly identified. Along with other advice, which is contributed as part of those assessments, does mean that you are getting good quality support for children who need that additional level of support. At the moment, one of the issues is the fact that if we were able to reduce the number of assessments that were going ahead because there would be more universal and targeted support at a lower level, then you could manage to contribute good-quality advice when it is required. Part of the issue is going back to what was in place in previous years. There is, at the moment, still a requirement for what we call a graduated response. In the past, that might have been termed School Action, School Action Plus. What you had was universal support and interventions that were provided by schools and settings, and then more targeted support, with some consultation work with an educational psychologist. Then specialist support that would have been provided with the actual direct involvement sometimes of an educational psychologist. The issue with the graduated response was that you would have more information and evidence by the time you were at the stage where there was a statutory assessment required. These days, a lot of educational psychologists would say we do not get the same quality of information and evidence for a number of factors that have already been cited. There is not that opportunity for schools and settings to try those interventions out, and for other specialist agencies to get involved to help support and provide recommendations and advice at a much earlier stage. In some ways, we could do a better job if we were able to put in the early intervention and provide much more information and evidence if a child or a young person was felt to need an education and healthcare needs assessment.

Speaking about early intervention, I wanted to ask Janet about a couple of programmes that the Government have invested money in. What impact do you think they have had? The first is the early language support for every child programme or project and the second is the Nuffield Early Language Intervention project. Do you think that these have had an impact on the early identification and support of speech and language needs?

I will take the second one first because I know less about that. That is not something locally that we have used. I know a lot of areas across the country have used the Nuffield programme. It is part of a system of support that would need to be in place and it relies on lots of factors around strategic sign-up, parental involvement, and so on. Just in and of itself, separate to everything else, those things are quite temporary; they can be quite short term. But embedded into a whole system approach to speech, language and communication needs and early identification, they can be good, and I know lots of areas are using it well. But I can talk about early language support for every child. It takes up a large part of my life at the moment. For the last 18 months we have been part of the SEND and AP Change Programme, and we have had an opportunity to develop an approach not just in one small geographical area. We decided to do it across the whole population of Leicester, Leicestershire and Rutland, so we have a large number of children now. The 35% that I referred to earlier, who were children who were waiting for speech and language therapy, who had needs that were requiring a much more universal and targeted approach, we have recruited a new staff team, speech and language therapists, and a bigger proportion of speech and language support worker posts. The therapists have been overseeing the competency development and training of those staff. We have developed nine new interventions based on the evidence for the most commonly occurring early speech, language and communication needs, which often, in our experience, unless dealt with early, obviously the risks increase for those children in terms of their educational progress and so on. They are quite often then referred to a number of different agencies because they have not had that early intervention. Some of those children go on to have educational health and care plans when they were not needed. It is because they have waited and not had responsive support. We have been running that now. We have a significant number of children who have completed that programme. They have waited a lot less time for their intervention. Parents are happy with it, satisfied with it. We have had good levels of responsiveness from settings and schools. All the settings and schools that we have worked in—and I am sure you will hear about this in the next session as well from Marie—like having the therapists on-site and the support workers on-site because we are not parachuting in with advice and clearing off again. We are coaching, we are working alongside each other. What schools and settings are doing—and this will be Lisa’s experience too—are using those strategies and the things that they have learned with other children without the need to refer them on. It has been cost-effective. The important thing about it is that it is part of the change programme and it sits within a strategic framework. We report on its progress to our change programme partnership, which is the three directors of children’s services and the local authorities, the ICB and ourselves as the provider, and we have all three parent carer forums as representatives. We are taking a whole system approach to embedding a systematic speech, language and communication structure and approach across our whole geography. The early outcomes are positive, and so we are highly recommending, as a Royal College, that there is a continued expansion, extension of that programme. We are part of the national LSEC pathfinder network, and everybody’s work across the nine pathfinders is going well. These are all areas that did not have something of its kind in place before. Lots of areas around the country have lots of universal and targeted great work going on. We think this is a model that you can lift and shift with support anywhere where that is not already in place.

That makes sense. You would want to see this rolled out everywhere?

100%.

That makes sense. What cross-departmental work needs to happen in order for it to be rolled out then?

There needs to be a joint commissioning opportunity for LSEC. In Leicester, Leicestershire and Rutland we have set up a standard inclusion alliance that will continue beyond the life of the change programme. LSEC have identified that as one of our top three joint commissioning priorities; the other ones are neurodiversity, SENDIASS’s support for families, and LSEC, so speech, language and communication. In terms of a strategic and policy-driven approach from DfE and Department of Health and Social Care, this is a recommended and more mandated way to meet additional need and to promote early outcomes for children. There needs to be much better cross-departmental working for that. We have seen it locally across the system but everything still comes to us in two separate channels. A combined workforce plan with combined joint commissioning arrangements and requirements, and we are also, because we do not expect that everybody knows this stuff inside out, recommending—there has been some previous work done on quality standards for good joint commissioning for SLCN and we think that that needs to be revisited cross-departmentally.

Both of those interventions are school-based interventions, which start once a child has already arrived at school. Is there a clinical case to be made for the application of a similar set of interventions in the early years so that there is even less need for catch-up once a child gets to school?

I should have said. That would be remiss if I had gone and not said this. It is 0 to 11, so most of our children locally are two and a half to three, so we are getting them before they even arrive in school because it is very interconnected with our healthy child programme and our early year settings. Most of our referrals are coming from health visitors or parents, from family hubs.

That is different for the Nuffield intervention, which is the reception-aged intervention, as I understand it?

I do not—it is not—ask Marie later.

We recognise that the staff shortages have an impact on how much direct support can be provided in educational settings. Beyond that, what challenges are your members facing? This is a question to Lisa and Janet to begin with. What are your members facing in those barriers to being able to offer that direct support?

The barriers that we experience are the fact that the funding, as I mentioned earlier, to local authority services has been cut. It means that we offer a traded service now, so schools that receive their finance directly from the Government can choose their EP provider. In my service, some of those schools buy us back in, and that gives us the opportunity then to work collaboratively with the school to be able to put in early interventions and talk about graduated approaches. We find that this service level agreement work that we are able to offer gives some job satisfaction to our members, which means that they hopefully want to stay with us and not look elsewhere for employment. That is one of the main barriers because I feel that we are very directed towards providing a contribution to the education and healthcare needs assessment. All educational psychologists are trained to be able to offer early intervention work and to be able to offer training, to be able to train the adults who are working with children with additional needs and young people with additional needs. We have a number of different ways in which we can offer help and support in schools, but it is having those opportunities and not being drawn into the statutory work as much as we are at the moment.

Out of those two, what would you say is the more pressing one? Is it the structure that means you are essentially a traded service rather than being funded as you would like to, or is it the demand for the statutory work around needs assessments?

The statutory work has increased phenomenally in the last few years. I think it is about 70% more since 2019, and that is reflecting the fact that there is not the universal support, there is not the targeted support, there is not the early intervention in place. Therefore, children and young people’s needs are escalating to such a high level that then the only way to address them is through the assessment process, which as local authority EPs we are required to support. Going back, when we used to be able to work and put in place a lot of early intervention, the number of requests for statements, and even early on after the Children and Families Bill was introduced, the numbers were still tremendously small in comparison with what we are measuring now. I think it reflects the lack of support and early intervention at a much earlier stage. I think that is one of the main things.

The challenges on behalf of the people that I see every day are that they deal with high levels of parental distress and dissatisfaction and different expectations, because parents are feeling they have to fight, so coming into that environment in a very distressed way—completely understandably—feeling that they have to campaign and battle for service. That sets up a dynamic in terms of the therapeutic relationship, which needs a lot of work early on in that interaction. As Lisa said, we spend a huge amount of time writing advice for education, health and care plans. I think we have said a lot about that, but I can have members of the team working all day on reports instead of seeing children, which just seems perverse. We deal with a real widening of health inequality in terms of access to service at times. In areas of our population, you will have huge numbers of parents very dissatisfied and distressed about the waiting times, and so on, and some parents able to advocate for that in ways and perhaps to seek to complain, and so on. There are large areas of our population that we do not get complaints from, and I think it plays out a huge health inequality in our demography Where there is a lack of join-up between—I think the question earlier between education and health, it is different priorities, different targets, different key performance indicators, different information sharing arrangements, different finance implications. At the moment we are dealing with a set of finance implications for new budgets for health. They will impact directly on SEND and SEND support, but it is happening separately with no joined-up decisions about how best to achieve some of that financial balance for the year. I think that one of the things that we see as a challenge, very much so—and this is something that, as the Royal College, we talk about a lot with our members—is that children and young people are not sufficiently prioritised within health systems. It is 25% of the population are 0 to 25 and there is a much smaller proportion of budgets perhaps spent on children. I think we all think that there should be a new statutory requirement for local SEND systems to jointly commission services for children with SEND because we would be in different partnerships having different conversations, that would be the aspiration. We realise the challenges are not a short-term fix, they are a real system and context fix we think.

The work of upskilling school staff in order to support them but also to relieve some of the pressure on health professionals and EPs, in your view is that an effective intervention and measure?

Yes, very effective. In our local area we run an ELSA programme, which is upskilling teaching assistants to understand more about emotional wellbeing. It is a successful programme. It is a national programme developed by educational psychologists. The training is delivered by educational psychologists. We also offer supervision so that the ELSAs, when they have completed their training, can maintain their accreditation so they get professional supervision from us. We also, as part of the six-day training, invite senior members of staff from the school to attend for part of day one. The reason being that the school needs to understand that they are investing in this teaching assistant in the training and also they have a role in order to support the ELSA. We currently have just completed training 20 ELSAs this year and we offer supervision to 80 across our region. We know that we get very positive feedback from all the schools where there is an ELSA, and many of them also train others so that in some of our large secondary schools we have two or three ELSAs working, and they support the capacity of the school to address emotional, social, and mental health and wellbeing issues.

The work that we did on the workforce for children and young people suggested that the therapy workforce, in particular, is nested in a range of different workforces. At the outer ridge, you will have education, social care, and you will have also the wider healthcare workforce beyond therapists as well. All those have roles within them, which play an important part in meeting needs. There is a question about how the different nested workforces interact with one another. There is also a question, I think Janet hinted at it, about skill mix within the therapy workforce. The skill mix is pretty rich. I do not mean that in a pejorative way but the figures I found were about six registered speech and language therapists to one support worker or assistant. I think there is an issue about how you might develop a more diluted workforce, which allows support roles and assistant roles within therapy to play a role. There are career pathways and competencies being developed, I know, in therapy to develop support workers. But skill mix, as well as interacting with other occupational groups in the wider socioeconomic sphere, is important.

At Royal College, we have been advocating models of working with schools and settings for a long time, and we are able to work alongside, especially some of the LSEC work that we have been doing and other work that you will hear about this morning. Staff in early years settings in schools need to have the knowledge and skills to deal directly, intervene, identify early any emerging speech, language and communication need, and to provide good speech, language and communication models, because it is the foundation on which everything else is built. You learn with language, so if they have the skills to identify emerging needs and put relevant strategies in place you do have a dynamic, which will then prevent the escalation of some of those children to the required specialist services. We are definitely recommending that there should be a strengthening of requirements for teacher training on SEND and speech language and communication needs. We have advocated for that many times in the past and it still seems to be quite minimal from teacher feedback that we get. To strengthen requirements for local area SEND systems to have good programmes of workforce development around SEND support, rather than coincidental, a bit fragmented.

Picking up on your points around skill mix. As you all know, the Prime Minister has said how important oracy is in schools and how much he wants to ensure that the work that we do on reviewing the curriculum gives that prominence. We have received evidence that working with therapists to upskill school staff to include teaching assistants, to increase understanding of speech and language support and staff capacity, is a way of creating a much more universal base level. Given the prominence that the Prime Minister is giving to oracy, what opportunities are there to link those two things together? Because obviously speech and language at that first stage is so important to then the skills that children and young people have in terms of their oracy skills and the jobs opportunities that that leads to later on. That is my first question to all of you. Then to Ian, in particular. Based on the research that you have done and what you found on workforce and access, what changes would you recommend to workforce, and what changes would you recommend to improve services, access, design and delivery?

The emphasis on oracy is welcomed by us all. I think that what we see in many areas of our population and across England are preventable, avoidable speech and language delay, that when children are exposed to good communication environments early on, whether that be at home, whether that is through earlier settings in schools, that that is what we are aspiring for for everybody. Human rights of the child, that is what we are aspiring for. Those models of health professionals, social care professionals, education staff working together around children with a shared understanding of what works well in promoting good communication development and good oracy environments, we would entirely support that. It has been a benefit having the opportunity again to do more universal and targeted work in schools and settings through LSEC. Those comments we have had already from practitioners around, “The work you have been doing around that individual child, I saw that as directly relevant to my whole foundation stage.” If we are doing a particular approach around developing vocabulary, for instance, and they have asked them for some training to be able to do that with the whole setting, we do that work in conjunction with earlier specialist teaching teams that work within the same context as Lisa. It feels like we do a lot of that work when we can, but we need to be able to do that as a commonly-based part of the system for all children, irrespective of whether there is any emergence. Those opportunities have diminished, so a return to be able to do that and to place communication and early development at the centre of that, but to have integrated teams that are able to do universal and targeted work with that mission to improve oracy, I think we would be really supportive of that.

I would say particularly EPs with their expertise in child development and promoting wellbeing and pedagogical practice have a proven track record of delivering high-quality training, which can contribute to the delivery of upskilling teaching assistants and teachers and educators. It is important as well that the training is identifying individual differences and it should include helping all staff to appreciate factors such as mental health and wellbeing, emotional regulation and systemic factors as well as a good knowledge of the impact specific interventions that can be put into place. I think the universal training to identify delays, perhaps, rather than differences, and to be able to know what things they could put in place without seeking advice from external agencies.

Of course, that also applies—we have not talked about it as much—in terms of parents. Lots of the models that we are talking about in universal and targeted support, we absolutely need to make sure we have spoken about the role that these services and family hub teams, integrated teams, play working together in local areas. It is on that very, very early experience of children and families working closely with parents that parents are given the opportunity to have models that are provided at home. Lots of that stuff we used to do 10 years ago and we do not do anywhere near that same amount of that now; if any actually. The role of parents in all of the things that we have talked about we should reinforce as well.

I am going to have to encourage all our witnesses to be a bit more brief. We have a couple more questions to get through. We want to hear your evidence but we have a slightly longer second panel to get through as well. If I can ask you just to be succinct in your answers as much as possible.

Ian, if you can come in on the question that I asked you about your research.

Clearly, the issue of workforce and planning around workforce is important. When we talk about workforce planning, workforce strategies, that clearly implies a systematic approach, which involves identifying the needs of the children and young people with SEND, and then developing a workforce that meets those needs. One of the problems is that we found that commissioning was—I say in the nicest possible way—a bit of a mess in terms of unevenness of commissioning approaches, what services were actually commissioned in different parts of the country. The different commissioning practices feed through into the workforce you need and which develops. If you have chaotic commissioning practices, you get a slightly disordered workforce that is developed to meet those needs. I know there are lots of models around. Marie Gascoigne and the balanced system approach is around identifying the needs of children and young people and developing a workforce that reflects those. At a more granular level, there are clearly issues around training and development, particularly of therapists, and we found that there were not a lot of programmes in all parts of the country that allowed particularly specialist therapists to develop. There is an issue about moral injury, which Janet mentioned, and a lot of therapists are disillusioned because they cannot do the professional activities that they were employed and went into the profession to do. They are involved in administrative activities. That suggests administrative support would also be very helpful in freeing up and allowing the professionals to carry out the professional tasks they were trained for. That is why skill mix is also important in freeing up professionals to focus on complex cases. Those are some of the issues. I think there is an issue about young people and how they view the profession. There are rotational posts and to what extent—there is quite a high attrition rate from young people going to therapists for children and young people to the point that it is a quite conflictual atmosphere and some of them do not like it.

But in terms of your research, what would you recommend to improve services in terms of design and delivery?

We were focused mainly on the workforce side. I know the balance system—Marie’s model—and there are other models from Care Aims, which talk about how the development of universal, targeted and specialist services then feeds into the workforce that you need to develop. Those whole systems models are clearly very important in terms of downstream workforce consequences. We will look at it more from the workforce than the service design perspective but clearly service design and the models you introduced, which has implications for commissioning, will affect the workforce you need to develop to meet those particular service models, if that makes sense.

Professor Kessler, sticking with the comments on commissioning referred to as potentially chaotic at points, obviously your research refers to a myriad of commissioning challenges. Basically what are the priorities, locally and nationally, for getting that sorted? What action needs to take place? What, if any, role do you see for the Department of Health and Social Care in sorting out that chaos, either by streamlining or supporting it?

A number of people have talked about the fact that you are dealing with a whole range of stakeholders and funding streams that need to be brought together in the commissioning process to develop a coherent and whole system approach to the delivery of these services. If we were taking our research forward we would look at ICBs and how they were developing strategies around this particular service space. I think there is clearly an issue about the space, whether ICB is the right space to do that. There is an issue about joint commissioning, which has already been talked about. The problem with a lot of these models is that they are wonderful and they are right, but we do not start ever from a blank sheet of paper. You have these myriad patchwork commissioning arrangements in place. They are very different in character and nature in terms of the type of services that have been commissioned and the way in which those contracts are serviced and managed, and getting out of those and changing attitudes and behaviours, which are established through those contractual relationships, is very difficult. We do not start from year zero and say, “Let’s develop a nice model.” We have a system in place, and we have to move to a new model. The question is how do we get from A to B? I think that is the problem; breaking down existing practices, habits, good and bad, streamlined arrangements that are meeting need. I think it is a complex process and these models are an important starting point, but they have to deal with a broader change issue about how you move from current arrangements, which are sometimes disordered and chaotic, to the new, more streamlined and arguably better arrangements that you are looking to put in place.

I would like to thank the panel for your insight and expertise that you have shared this morning. This is your final opportunity to add anything that you may not have shared beforehand in in terms of encouraging and enhancing greater collaboration between health and education services and local authorities.

I think that there needs to be an emphasis, and we would strongly recommend the emphasis on SEND support rather than a focus on EHCPs, and that the joint commissioning arrangements are a statutory requirement around SEND support with a focus on prevention, early identification and early intervention, to try to escape the system that we are currently in.

Echoing what Janet said, I think that a national specialist workforce strategy would be helpful to oversee what specialisms are out there already and how they can be better used. Going back to the idea of Every Child Matters, building up publicly-funded services that work around children, young people and families, and echoing some of the values and principles that were in place with children’s centres and Sure Start. I think also you need to ensure that there is sufficient specialist support services within each local authority to give equity to access those specialist forces for every child and young person in education settings. The support needs to be there to help them, as we have discussed, with the universal support, the targeted support, as well as specialist support when required. Obviously from the AEP point of view, we would like to see an increase in the training of educational psychologists each year, so that there would be an educational psychologist available for each school. It is very hit-and-miss at the moment. As we mentioned earlier, as a traded model we do get buy-back from some schools, but other schools we do not know whether they seek out other EP providers or whether they just go without. But I think it would be helpful if that would be a target for a workforce strategy for educational psychologists.

I would encourage you to read our wonderful report, which covers a lot of the issues we have talked about. I suppose the one point I would make, and one of the reasons our report was actually commissioned, was that we do not know what the workforce for children and young people with SEND looks like because responsibilities are dispersed across a whole range of sectors and occupations. It is difficult to get a handle on what that workforce looks like. There is work that is being done that we uncovered in the Department of Health, which is trying to map what the workforce looks like. It is not just therapists or education psychologists, a whole range of other occupations. But what proportion of their time do they spend on children and young people with SEND? What resources do they have? That is all hidden in a broader system where responsibilities are much wider than just simply children and young people with SEND. The work that we identified—being done in the Department of Health—surveyed ICBs, asked them what their funding was and exactly how much of that was devoted to workforce. They came up with a workforce of about 18,000 in the Department of Health across different occupations, focusing on children and young people with SEND. But I think there is still an issue about what the workforce looks like, not only within health, but also within education. If we are looking at teaching assistants, what proportion of time do they spend with children and young people with SEND? There is, I think, a simple mapping exercise to be done about what the children and young people with SEND workforce looks like. What you need as a baseline to explore how it might be developed and taken forward in the future.

Thank you, that is extremely helpful.

Thank you very much. Can I thank all three of you for coming to give your evidence to us this morning? Can I also say, if there were matters of detail that you were not able to convey to us because of time constraints this morning please do feel free to write to us afterwards with that. We are very keen to have as much detail from you as possible. Thank you very much. Witnesses: Marie Gascoigne, Sarah Walter and Alison Stewart.

I will resume our session with our second panel of witnesses this morning. I invite you to introduce yourselves to us, starting with Sarah Walter.

Hi, thanks for having me here. My name is Sarah Walter. I am Director of the Integrated Care Systems Network at the NHS Confederation. The NHS Confederation is an independent membership body that brings together, supports and speaks on behalf of the whole healthcare system across England, Wales and Northern Ireland. I run the Integrated Care System Network within the Confed, so representing the 42 ICSs in England, both the integrated care boards, which are the NHS commissioning bodies, and the wider integrated care partnerships that bring together the NHS and local government.

Good morning. Thank you for having me here. I am Alison Stewart. I am the Head of Special Educational Needs and Disabilities for South West London Integrated Care Board. I am a speech and language therapist and psychologist by background. I have managed large therapy services and I have also been a designated clinical officer for children and young people with SEND.

Hello. My name is Marie Gascoigne. I am also a speech and language therapist by background and have worked in numerous roles, including a spell at City University working as an academic and also leading NHS services as an AHP lead before moving into a more policy-focused area, which is what I am talking to you about today, I believe.

Thank you very much. The National Audit Office has said that misaligned priorities and incentives across the system undermine a whole-system approach to SEND. What action should be taken at national and local level to align the priorities and incentives of the education and health services to get them working better together to deliver a more strategic approach to SEND and better support for children and families?

This is an issue that we hear a lot; not just around support for SEND but across a number of different areas. That lack of alignment that exists between the NHS with local government, with education and other parts of the public sector. We see that financial incentives can drive different bits of the sector apart. Funding cycles are not necessarily joined up or aligned across different departments or agencies and that creates practical problems for local systems and commissioners to try to pull budgets to work more on a joint basis. Short funding cycles, those kinds of issues around small pots of money rather than having a clearer planning cycle and longer term budgets across different agencies, that then creates an environment that supports local joint commissioning and planning of services. It is something we hear a lot from members.

I agree with everything that Sarah said. From my perspective in terms of my role working within an ICB, we do absolutely see this challenge between the different priorities across local authority and the NHS. We have a challenge within the NHS in terms of where children and young people are prioritised. There is also a challenge around what SEND means and what it means within health services, and we have to be mindful of the language that we are using. I am encouraged by the methodology of the Area SEND inspection framework, looking at the way the local area works together in order to look at how this shared responsibility works. That is where we are looking at how we ensure that we have shared responsibility and accountability across education, health and care. Further joining up in terms of DfE and the Department of Health and Social Care would also support that.

If I take it in a slightly different direction; I think there is a misalignment in culture and philosophy that is at the root of some of these challenges, that then turn into the processes and structures. It is very fundamental that we have a difference between perhaps a more developmental, social model that would perhaps be more familiar in DfE land, and a more medical model in the traditional health context. Certainly the work that we do that is successful is trying to address that head on. There are lots of willing parties in all of those structures that exist often, but they are facing these fundamental differences in how they have been brought about in terms of their structures. There is something fundamental about thinking around culture underneath it all as well.

Thank you, that is interesting. Sarah, a 50% cut in the budget for ICSs, a 50% reduction in capacity across NHS England and the Department for Health, and the abolition of NHS England; what impact will that have on the challenges that we are talking about today?

It is inevitable the turbulence the integrated care boards are responding to at the moment and an environment that has a great degree of instability will have an impact. We are working through with integrated care boards at the moment, working with colleagues at NHS England and the Department about how those 50% cuts will be delivered and what the future model will look like across England. It is likely that we will see change potentially to the number, shape and size of integrated care boards. That does create an additional degree of instability within the system I suppose. Integrated care boards have existed for less than 3 years and have already had a 30% reduction in their running cost allowance and now are subject to this 50% cut. It is unsurprising perhaps that that has been a hindrance to some of the attempts to develop greater collaboration and partnership across local government with schools and other partners. Saying all of that, I think there is also an opportunity here. We are talking about integrated care boards having a focus on strategic commissioning and that role looking at an in-depth population needs assessment and thinking about how you commission for the outcomes that you want to see for your population. Through the 10-year health plan, which we are expecting to be published in the next couple of months, we are anticipating a focus on greater neighbourhood health approaches, towards a more empowered and preventative model of care. It is important to look at what is the role of the integrated care board as a strategic commissioner, and recognising there is a lot of change in that space at the moment, but also how does that happen across the wider health system. What happens alongside to support greater devolution, to place based working, to expanding a kind of neighbourhood health service—which I think is the desired outcome from the 10-year health plan—and leaning into some of those local opportunities to develop partnerships across the NHS teams with local government partners, schools and voluntary sector partners. So there are opportunities there as well but it is inevitable that the kind of change that people are dealing with at the moment and the pace of that change, which is happening incredibly quickly, will have an impact practically on the time and headspace that ICB leaders have to put into some of these arrangements.

May I add something to that? That is a helpful context. Within the world of SEND what we tend to see is a lot of the activity sits at place, it sits within the local area. Rightly so, I would suggest, because that is where we need to make sure that we have that whole system ownership and accountability. There have been some challenges with the structure of the ICB as has existed previously in terms of what happened centrally and what happens at place. Certainly from a south-west London perspective what we are trying to look at, at the moment is ensuring that we are developing our infrastructure around SEND at place. That needs to be much more than a designated clinical officer in a local area. It has to be the infrastructure and then ensuring that we have adequate governance and accountability into the wider organisation. But I think it has caused quite a lot of confusion across local areas.

I am guesting from the Public Accounts Committee and thank you for your contributions so far. Obviously since the Children and Families Act in 2014 we have over a decade now of attempts for joint working. I think back in 2015 there was a SEND code of practice and it described that partners must agree on how they will collaborate to provide personalised integrated support across education, health and social care, creating positive outcomes, smooth transitions for children into adult services. From all the evidence that we heard at the Public Accounts Committee—and I believe in front of this Committee—it would suggest from our education and local authority witnesses that health is not stepping up to the mark. You look at waiting lists for speech and language therapy, the very long waits for autism and ADHD assessments, and the sense that it is not working, the joint approach. What more needs to happen? There are a few ideas specifically I will put to you but perhaps, Sarah, do you want to go first?

I think we need to look at the environment that the NHS is operating in and how the national priorities and directions are set. It is clear at the moment that there is a real focus on recovery of services, on the financial challenges that the sector is facing. We see sometimes a misalignment I suppose between the desire of ICS leaders—both integrated care boards but also the wider integrated care partnership, which often brings together the NHS, local government, with other partners including across education and the voluntary sector and more widely—with a desire to have a focus on the longer term health outcomes on the population. A lot of focus on children and young people within that ICP context, so lots of integrated care partnerships have prioritised children and young people support as part of their five strategies and that is set out as a local ambition. But the national environment and some of the priorities that come through at a national level at the moment certainly feel very fixed towards a more short term and financially driven approach. There is a clear need for the NHS to recover services and there are significant financial and performance challenges at the moment, but some of that then crowds out the ambition locally to have a greater focus in some of these partnership spaces and for children and young people in particular. We are seeing some of that local desire not always mirrored at a national level and the pressure that then come through onto NHS leaders to deliver on those immediate, often more acute based priorities, has led to that kind of crowding out.

In the Public Accounts Committee report we said there was this risk of a lost generation because so many children are not getting their needs met at the earliest opportunity. We have had evidence from an organisation Contact, they are suggesting perhaps a joint legal duty across health, social care and education. We heard ideas from the previous panel around statutory joint commissioning. Do you think we need to tighten up? At the moment the accountability sits with the local authority and yet they do not have leverage over their health partners.

Yes, in short, I would absolutely agree with that. As Sarah said, we know what the situation is in terms of different priorities. We have to move with statute to a position of joint commissioning where we are looking at how our services are being designed. It is about looking at how do we enable services like speech and language therapy, for example, to have commissioned time to have the flexibility to work at a universal targeted level as well as that specialist level. It will be important. I think also increased accountability comes with that and that again has got to be an important thing. With all of this it is about how do we work as a whole system. We have children waiting, and we can talk about children who are on waiting lists for neurodevelopment pathway, for example, for far too long in my opinion. However, for some of those children they will be getting support from other bits of the system, and other bits of the system can provide some excellent support. Sometimes we are driven into a position that we are splitting education and health rather than looking at a proper needs-based approach to children, the right support at the right time. So if a child is on a waiting list for a diagnosis, are we confident that they are getting support through organisations like Portage, family hubs, and so on, in order to build a much more robust and sustainable approach to support for children and young people.

I am conscious that you are particularly health but social care is also part of this join up. Is there anything more there that you see needed to bind social care in?

Yes, I think there is. For a long time we heard that message that health is not coming to the table, health is not playing ball, if you like. I think there are similar conversations around social care. Again it goes back to the point about the local area and the system. How do education, health and care work together? We know that many local areas have increased their use of the designated social care officer role, which is great. However, that also comes with the same sort of risks that the designated clinical officer role holds. These functions cannot be delivered by one person alone without a suitable infrastructure and clear accountability. There are elements of particular programmes that we need to think about and I do not wish to take us off at a tangent but something like All Age Continuing Care is an area where we know that join up between education, health and care is absolutely vital and needs some attention.

I think we will be coming back to some points there but thank you.

I would like the panel to tell us in your view what are the key barriers to the effective provision of health and medical support to children with SEND in education settings, and what measures are needed to address these challenges? Also, one of the proposals that we heard was for clinical staff to train school staff to provide support for children with complex medical needs. Without this clinical support in the school they might not be able to be in school and so they miss their education journey. In your view would this be effective approach or are there potential limitations?

Yes, so where to start with that one is the first thing I would say. Children go to school, children are required to go to school by law, children will have medical conditions that need to be managed during the school day. I think that is the bottom line. We know that is addressed through the Equalities Act through the DfE guidance on supporting children at school with medical conditions. But there are a number of questions that come out of that, which include what clinical tasks can be delegated to teaching assistants for example within a school setting, given that some of those teaching assistants will not have volunteered to take up a job where they are delivering clinical interventions, so there are some questions there. We also need to make sure that our offer in terms of training to schools is robust enough around whatever that child’s medical condition is. Locally we have had some good examples where we have had joint funding of healthcare assistant type roles for children with very specific conditions, things like epidermolysis bullosa, the skin condition. That is not a special educational need but obviously physical discomfort and pain will impact on a child’s ability to access education. We need to be in a position that we can think about slightly different ways of funding that. Across south-west London we are doing a piece of work at the moment around the way that we manage requests from local authority from schools for additional funding for children with medical needs. There is no statutory guidance on this as things stand at the moment so we are looking very much at what the clinical evidence suggests and the impact of the child’s medical needs on their ability to access education. In short, there is a lot of work that needs to be done around this. Some of this is under way already. Some of it is related to what are the tasks that we can reasonably ask school staff to do while also delivering the curriculum, and I think there is a question there. Then what is the support and training that is available from health services in order to do that.

I am not sure I have a huge amount to add to Alison’s assessment there. It is probably outside of our area of expertise in terms of the medical needs of children, but I think it does come back to that principle about how we are approaching these questions from a systemic perspective, a link to the cultural point that Marie raised earlier. So much of that is based on the ability to have those place level, neighbourhood level relationships and teams to be able to understand the needs of the population and how the various different agencies and professionals involved can work together to best support working across those different boundaries.

I was being quiet because it is a very specific end of the continuum of need that is seen in settings. There is something around not making the assumption that we know what medical needs are in everybody’s minds. Alison gave some very good examples there of very specific medical needs; in fact the example you gave is not necessarily a special educational need in itself. There is a much bigger issue around what we might appropriately delegate to colleagues in schools that is easier to do and monitor but there would still be this caveat that it has to be supported by the expertise on a regular basis. It is not about saying, “Here is a training programme, off you go and you will be fine.” Whether you are at the very, very acute end, if you like, or at the broader end—that I guess we will be talking about more as we go through the session—I think there is something around that monitoring and coaching that is part of that. In some respects it will be about safety, it will be at the very sharp end and in other aspects that we will be talking about it will be a broader level.

Can I ask what level of urgency you perceive particularly within NHS services around this? The evidence that we have received points to a characterisation, that would not be inaccurate, that describes this as a wild west in the education system, both in terms of where the funding is coming from, very different across different places. High needs block funding that is under intense pressure being spent to meet medical needs that should be met by the health service, and a whole wide range of different types of staff with different qualifications with absolutely no clinical or governed framework around the training that those staff get, delivering a wide range of support in schools. I have to say, it is pretty terrifying to think about the level of risk that non-qualified, non-clinical staff are carrying in school settings, that school leaders are carrying at the moment. It also seems to me to be profoundly unfair that local authority budget should be spend meeting straightforwardly NHS responsibilities.

I agree with you on that. I think there are real questions about where it sits as a priority in terms of NHS conversations. If we look at something like the NHS long term plan where we are looking at conditions like diabetes, for example, or asthma, in a way that is following a very clear pathway. The children I am talking about here are those whose medical needs, whatever they may be, are impacting on their ability to engage in a classroom, be in a PE class, manage lunchtime. They do not fit in a neat box. We are looking at a whole range of needs and it therefore does require careful thought to work out if we look at the way school is using their notional budget, for example, in order to meet a level of need, what is the bit that is over and above that, that as a health system we need to be responding to. There has been recent union information out for teaching assistants around the fact that they can say no to taking on some of these tasks, and I think that is right. But then we have that question of where will that be addressed if our sometimes fantastic, well-meaning TAs are saying, “I don’t feel comfortable to do this”? One of other themes that comes into this conversation is definition. As Marie said, we can talk about medical needs that do not necessarily mean SEND, but if we have a young child with diabetes, for example, where the diabetes is still quite unstable, they are in a free flow classroom, who is monitoring their insulin levels? There are questions there. We then have that interplay that child and the family may become anxious about going to school. How do we make sure that as a system we are responding appropriately to that in a timely way, rather than thinking, “This bit is diabetes and this bit is emotionally related school avoidance.” The two come together and we have to work together to address that.

Sarah, did you want to add anything?

It is how you are coming together to address those issues; I think that is the intention around the more neighbourhood health-based approach where you can develop those kinds of relationships. Things like the question around where is the risk being carried, is that being agreed up front, what is the risk here, who is holding that, how are we supporting you to manage that? It is wanting to get to a place where the way that we are supporting children has been explicitly discussed and agreed with all partners acknowledging the part that they have to play in that, rather than the wild west situation that you have described where it is not a planned position, it is people making the best of the situation that they can. I think it is about how we get to a place where we are much more upfront having these conversations about the particular individuals and population that we are seeking to support, and what are the roles of the different professionals and agencies in doing that.

I want to come back to the high needs block fund and also what should come from the ICB commissioning services fund. For example, allergies; we know that lots of children are having allergies in schools. To train the school staff, because it is not a question of being a nut free school, there is also training involved, EpiPens as well, where do you think the funding should come from and who should deliver that training to staff?

The current position is that will predominantly come through public health commissioned school nursing. Again, the school has a responsibility to work in partnership with health colleagues around drawing up an individual healthcare plan for that child. Not the same as an education healthcare plan, obviously, but that does give the blueprint for the school in terms of what to do in a particular situation. We need to make sure that the training around something like allergies—which is a fairly common need—is adequate and that schools have access to resource for support around that, particularly if there are questions that arise in everyday practice.

I want to go back a little to the SEND and joint commissioning. I think we are all in agreement that there is some strengthening needed around the engagement of health and perhaps social care in joint commissioning arrangements. Some of the evidence the Committee has received from the Council of Disabled Children talks about outcomes-based commissioning; clearly that is predicated on having robust data and information sharing between all of the agencies involved and I guess SEND support as well as EHCPs. I am conscious that we tend to be focusing more on the EHCP delivery but as you have pointed out, we need to make sure this is joined up in terms of wider SEND support. I am interested to know your thoughts on how we move to getting that robust data and information sharing? Also with the introduction of the unique identifier proposed through the Children’s Wellbeing and Schools Bill, whether you think that will help create this collaboration and shared data?

I do not think I answered directly the point on should there be a statute around joint commissioning; absolutely, yes. But I think it needs to focus right the way through the system and not be focused on EHCP provision, because once we get there we have failed for a large number of children. That is what we definitely know. It has to be about the whole system. The unique identifier is an interesting concept that could have huge opportunities because what we should be doing, in my view, is taking a population-based approach because we do not know who the children are when they are born by and large—with some exceptions. Therefore, if we culturally shift the system to a better place of anticipation we need to move into that space of commissioning for anticipated need, not waiting for it to knock on the door because by then we have failed. What we know in the speech and language arena is that the long term trajectories for children who have not been identified and intervened with before five will be seen right the way through into adulthood and their lifespan. So, yes to joint commissioning, absolutely, but it needs to be on a different basis from case by case. While the unique identifier will generate excellent data in a longitudinal way, we need to not wait for that, we have to get in there in that anticipatory way straight away if we are going to do something meaningful, otherwise we will have another lost generation essentially.

Are there other sources of data or information that you think we should be gathering to be in that more anticipatory approach?

Certainly. There is a lot more evidence coming through and being published all the time around the risk factors that we can identify in populations, whether it be demographic, whether it be more specific family-based intelligence that could potentially be gathered that is not at the moment. If we start with demographics, we know that is a strong indicator. For instance, some of the work that we do, we would look at the demography of an area, we could go down to Lower Super Output Area, but certainly at ward level or at neighbourhood level, perhaps thinking forward, “In this neighbourhood we predict that there will be more children and young people that will benefit from some focused commissioning around needs—even though they may not be knocking on the door yet—and that we should be disproportionately directing some of our resource, but also thinking about whether the qualitative nature of what we offer is also differentiated for those populations.” Maybe we need to be doing things in areas that we predict will have higher needs that we might describe as targeted elsewhere, but we offer them to everybody. There are nuances there that could come through, but the commissioning system certainly is not sophisticated enough to deal with that now.

I recently visited an early years provider. One of the other things is, are we getting the same level of data as we might expect through schools? But obviously as we move towards more publicly funded childcare hours and also school-based nurseries, whether we can bring in more data on early years settings as well. Is there anything, Alison or Sarah, you wish to add?

Yes, a couple of things there. I agree with Marie in terms of system and, from a health perspective, we can work better on the join up between local maternity services into ICB commissioned services, into our public health commissioned services. There is the point about anticipating need but there is also something about how do we—the royal “we”—as a system provide wraparound support for families where need is identified at that acute point. On your point about data, it is a huge challenge. If we can make some progress on mandated information sharing, that would be really, really helpful. We are currently working on the development of our south-west London-wide SEND data dashboard, which has been a useful exercise, but it has demonstrated that the data that comes throughout the system is not nuanced enough for us to be able to pick up our children and young people with SEND coming through, moving away from reporting on an 18-week wait, for example, to something that is much more meaningful. If we could move towards an outcomes-based commissioning model, that would be fantastic. That will require a huge amount of thought, very, very careful thought, about what those outcomes are because, as we have said already, we are working across culturally different organisations. My definition of a healthy child will include aspects of development, emotional and mental health wellbeing as well as some of those acute medical conditions.

I need to ask us to be more succinct, given the number of questions that we still have to get through.

The only additional one on the data is where we do not have shared boundaries between local authorities and health, which is a quick point on that additional challenge.

It does add a challenge in there, recognising that we may see further change to integrated care boards over the coming months as part of the response to the 50% reduction that the Chair referenced. Seeing whether that can be a help in some systems but a potential risk and that sense of coterminosity has always been a real asset where systems have that ability to develop those partnerships. One quick thing that I would add in on the commissioning front is that there is a real need to build that commissioning capability, certainly within the NHS and moving into more of the joint commissioning arrangements. ICBs’ future role is seen very much as being a strategic commissioner but there is a recognition in all parts of the system, nationally and locally, that we have not had as much development of those commissioning skills and capabilities and some of the expertise on data intelligence and analysis and how that is used in commissioning decisions. That is an area that certainly we have been calling for greater investment and development in over this period.

Thank you, that is an important point, and sorry to slightly cut it short.

I only have one question. The age at which young people transition from education, health and care services tends to be between 16 and 25. For most it is 18 but those with EHC plans can transition anywhere up to the age of 25. The County Councils Network and the local government authority have both called for the standardisation of this age to ensure that there is a seamless transition between children’s services and adults’ services. Do you agree? Would you call for the same? If not, why not?

That is easy; I would agree. One of our challenges at the moment is that we have services that are commissioned from 16 to 18 and to 25. I think that that would help. Where it may take some time to get there, we also need to dedicate some resource into specific roles like transition workers within services to support individual children, young people and their families that come through the system.

It is not an area that we have an opinion on.

I agree with Alison that it would be a good idea and that it would be helpful. There is another set of challenges in there, which is that commissioners and providers do not know who the right people are to take those young people into adulthood, regardless of how they are described, within EHC or otherwise. That is a slightly different point but it is a reality that would need to be surfaced if that were to happen.

Thank you, nice and succinct.

Thank you very much. I am going to prolong it ever so slightly by saying that agreeing that there is a need for alignment begs the more difficult question of at what age?

Preparation for adulthood starts at 14. I do not think that we will get our health services moving to transition at 14, but certainly at 18, at the legal point of adulthood, as a minimum standard.

I do not think it is fair. That would be the first thing that I would say. There does need to be an increased accountability for the local area, the local system. That should be the local authority, the ICB and the providers. Greater joined-up working between the DfE, Department of Health and Social Care, Ofsted, CQC and so on would help some of those conversations. It goes back to the point that I made earlier about the infrastructure around SEND within an ICB. There is a risk that where we are looking at a very small workforce taking that responsibility at an ICB level, we have to have an infrastructure around that. We have had helpful guidance from NHSE on the role of the executive leads for SEND within ICBs, which is great, but that does not take away from the fact that that person may then be executive lead for many, many other portfolios, so again there is a question there.

Sorry, could you repeat the question?

It should be more equally spread. However—I am going to sound like a broken record here—it comes back to the notion of a shared understanding of what we are accountable for, which is important because there is a danger that what the local authority feels accountable for and is frustrating is so integral to education and delivering and enabling learning that they do have an accountability that is appropriate. Where it goes horribly wrong is where there is a notion that the health bit is very medical. It goes back to my first point about defining what we mean by the support from health services and health therapists across the piece into that education and learning space. They are not doing things that are medical in the way of some of the other medical interventions that we were speaking about earlier. Therefore, there is an alignment of whether something becomes described as a medical responsibility because it is done by someone who happens to be registered with the Health and Care Professions Council or whether it is what they are doing and enabling to happen. That is the bit that I think is the muddle.

I agree with that. It comes back to the point on how we are setting the outcomes that we are seeking to achieve for a population, how that is being set nationally and the join-up that we are seeing from different Government Departments and seeing that mirrored through our various accountability routes within local government and the NHS and, where there is an interdependency between those different sectors, that that nuance is reflected in accountability systems rather than a setup where our accountability structures remain very separate.

As a brief follow-up to that, we had talked earlier about some ideas about how you might compel health. One idea is around tribunal recommendations and whether tribunals should be able to issue binding recommendations on both health and children’s social care.

I would be anxious if we continued to push things up towards the level of the tribunal and tribunal decisions. That continues to reinforce a very difficult model for children, young people and families. Having said that, I think that it would be helpful to make the recommendations enforceable rather than non-binding for the cohort who go that way, but there is something that we can do before that, which is looking at mediation and how we work on mediation across education, health and care at a much earlier stage. In dispute management what we often see is that complaints around the experience of children and young people with SEND come into the local authority, they sit with the local authority and do not always make it into the health service field of complaints management. That reinforces some of the challenge that we have with accountability. If we could get to a position of robust joint dispute resolution where we are looking at how the combined offer, the combined services for a child or young person are contributing to that complaint, we may get to a much better place of resolution.

My sense is that the preference is to start with joint commissioning, if we got all of that right, but if things do end up in tribunal there probably is a need for some stronger binding recommendations but we must not rely on that. Have I summarised that broadly?

Yes, and we do not want to be driving the system even further into the tribunal route. If we get, as you say, joint commissioning—I think that joint dispute resolution would be helpful.

We have lots of cases that go to the tribunal at the moment. When those cases go to the tribunal and the tribunal makes a finding that is not in favour of the local authority, all of the responsibility for meeting that need within that statutory framework of the tribunal sits with the local authority, which local authorities tell us is not fair. I would also highlight the injustice that sometimes the reasons why that need cannot be met, resulting in the tribunal ruling, is because they have not been able to get health to come to the table. Therefore, I feel as though we are having quite a hypothetical discussion from our witnesses today for what is a day-to-day lived reality that is very, very urgent for local authorities at the moment. I want to press you a little bit further on the urgency of that. The question that we have been asked by lots of people who have given evidence to us is how do you get health to the table?

The first thing is that we cannot manage this only thinking about the tribunal response. The initial point has to be the development of the education and healthcare plan, do we have good enough advice from our health services around the table at the beginning in order to inform the development of a plan? Where we have health needs that are not designated to educate or train, they should go into section G of the plan in terms of provision. We know in the tribunal that then non-binding recommendations can be made around that. That is the much smaller proportion of need. Some of our challenge with the section F provision is speech and language therapy and occupational therapy, where it is something that educates or trains. I think, I am afraid to say, that it does go back to how we are working as a local system and how we are jointly commissioning in order to meet that need. That joint commissioning also needs to be robust enough to have strong contract monitoring to ensure that the services have flexibility to meet population need, changing population need and so on over time. Therefore, it is a bigger piece rather than just the outcome of the tribunal.

I hear what you are saying about it being a live issue at the moment, but it is the wrong question fundamentally. We have to prevent people needing to go to tribunal, through giving confidence and giving a good service further upstream and, as Alison says, going back to all the things that we have to put in place to do that because a tribunal should be a last resort. That is what it was there for originally and now it is being quite a norm, which is clearly not helpful.

I will not comment on specific measures around SEND because colleagues will be better placed to do that, but with our broader ambitions for a 10-year health plan we would like to see a clear set of policies that focus on supporting health, that much more proactive, anticipatory approach, and not just about the NHS but a 10-year health plan that reflects—the NHS is one component part but we need to be operating as a system. We want to see a clear expectation, a commitment to reduce acute sector funding as well so that we are moving more into those community and neighbourhood health approaches and developing new care models. Colleagues have described very effectively and the Committee has clearly seen that the current situation is not sustainable and is not desirable in its current form. How are we thinking about the commissioning of services differently, looking at a much more systemic approach to SEND as well as other areas and developing those neighbourhood models of care? Those are some of the principles that we are hoping to see through the 10-year health plan, but colleagues might have more to say on the specifics.

I do think that children and young people with SEND need to be prioritised within the 10-year plan. They do not fit neatly into asthma, diabetes, complications of excess weight and we need to be aware of that. That is about improving overall child health in its wider sense and looking at reducing inequalities. It would be helpful if we were able to identify the specific ICB spending on children’s services. There is a challenge around block contracts where it is very difficult to extrapolate what is spent on children’s services. I think within the 10-year plan we also need to look at the drive to reduce waiting times for some of the diagnostic pathways, particularly neurodevelopment, but as a wider system piece looking at the services across the local area. Co-production, working with our parent carers with children and young people, is a strategic priority. It is something that we have not talked much about this morning. I think that that has to be pushed up the agenda to make sure that we are responding to what people are telling us about what is working. Service specifications need to be reviewed to consider children’s services, and metrics need to reflect the legislation on the SEN processes as well so that we can pull that data when we need to.

The neighbourhood model is absolutely an opportunity to be reinforced and the workforce needs to be built around those neighbourhood needs, picking up on the earlier point about the anticipatory element to that. The therapy workforce across the piece—speech and language, OT, physio being main ones—should be absolutely commissioned and thought about and planned for as being part of those neighbourhood teams so that they can be part of those local systems from the off, offering informal advice to families, working with colleagues on the ground, coaching those wider workforce members on a day-to-day level basis, not coming in as the specialist. Personally I would like to move away from the badge of once you see a therapist you are in the specialist space. Therapists absolutely can be more impactful right the way through the system. My last point, going back to outcomes, is that there is no point in having an outcomes framework if we do not measure impact. Counting inputs is not the best use of any unique identifiers or any other element that we might bring into the space.

We will now look to consider best practice. The Committee has heard previously about different interventions that have improved joint working, for example the Balanced System, the PINS programme and the Link programme. In your view, should these programmes be rolled out across the country? I will start with Marie, based on your previous experience.

I am possibly slightly biased on that one. I will declare that. It is my firm belief that having a whole-systems approach and a whole-systems framework enables partners across this complex landscape, this wild west, as the Chair described it a little while ago, to at least see where they fit together and have a common set of ambitions. As you may already have heard, we are talking about all of the domains of supporting families, looking at environments, looking at our workforce, identifying and intervening, but with a really clear premise that the intervention is more impactful if all of those other areas are being considered at the same time. I would absolutely say that whether it is that particular way of articulating it or a different one, it does not matter, but it allows us—for instance, in a live project we might be working with at the moment, it allows our education colleagues to understand that the ordinarily available is essentially that universal offer that is happening at place in terms of schools and settings, but there might be a universal offer in the early years that can be tagged into where that is happening. There will also obviously be the full progression through to more specific interventions and programmes. Where some of the programmes that you are asking Janet about earlier fit into that is that they fit into the whole conceptual framework and it allows us to avoid duplication of effort. Where we do have something like the NELI, the Nuffield programme that you mentioned, that is a brilliantly targeted offer but there might be three or four other offers. A local area can then take a view as to what is appropriate for their area. I would say that that on its own has been very impactful to enable partners to see where they fit together, even if there is further to go.

I agree. No disrespect but it does not really matter which model we are looking at but it is a model that is built on a whole-system approach to support. Any intervention must be built on strong foundations around that ordinarily available provision. Again, that is where we are looking at multiagency teams coming together and working together. Speech and language therapists receiving training around the curriculum, for example, is a valuable tool to understand how to work on vocabulary, for example. We need to build on that learning of that multiagency network so that we have the right people delivering the right support at the right time. I have some reservations—you mentioned this earlier—about some of the short-term funded projects where there are very tight timescales. It has to be delivered within two terms, for example. There can be some risk with sustainability there. We need to look at building up whether it is communities of practice or cluster groups of schools so that we are sharing that expertise. We can also sometimes not give enough credit to the expertise of our education colleagues and that can add to significant frustration. The specialists are coming in to give advice on things that they are already doing, have been doing and do day in, day out.

I agree with all of that. I would add that it is having those core frameworks in place, being clear about outcomes but not necessarily mandating a blanket approach, because different places and different neighbourhoods will have their own community assets or have their own relationships. Having that degree of local flexibility about how you deliver and what the specifics are within your local area that will achieve those outcomes rather than having a set script that everyone needs to follow. Getting that balance between consistency of where you are trying to get to but some degree of local determination and empowering local leaders to make those decisions.

I hear you about framework and context but are there any specific examples that you can share of really good practice? That question is for across the panel.

We have data emerging from a number of local systems that are playing to the waiting-list interest at the moment, which was not the original intention. I have a few examples—I will perhaps not name there here but I can send some data through following the meeting—for instance seeing where they have moved towards open access, taking away the referral, saying, “No, we’re going to be taking our therapists out into family hubs, out into schools. Parents can just turn up and we’re going to advertise that”. They are seeing that their referrals are going up, as in the people coming into contact with them are going up, but they are dealing with them immediately. I have some quite remarkable drops that people are reporting, for example in the first three months a 50% decrease on the need to go through, which echoes what Janet was saying about the LSEC programme, with 35% perhaps not needing to go through but might have sat waiting. Therefore, there is something important about that easy access, as Alison says, however it is done. Being at place, I would urge whatever influence the Committee can have to suggest that therapists are out in those community bases and not sitting in clinician settings unless it is necessary for what they need to do specifically for a child.

Based on that, in terms of resources and Government support, would there be any additionality that would be needed to implement such intervention if we did that nationally?

We do not have the answer for what the right number is. As Professor Kessler said, it is a very complicated question. We believe that there probably is not enough or we would not all be still be battling on over the years to do it. However, what we are seeing now—again I can give a compare and contrast. We have an area that is extremely challenged in its workforce, relative to population size and need, who have nevertheless gone for it and are seeing these dramatic improvements. It is a bit of yes, I do believe that there is more resource needed, but more resource into the broken systems of the very medicalised model is not good use of public funds, whereas more resource into something that is more impactful absolutely would be extraordinary.

I was recently at a family hub in my constituency looking at some of the work that they do, as effectively reinvented Sure Start centres. Given the things that we are talking about, that need for better integration between health, education, early years, and given the fact that they all continue despite extra Government investment, to have structural and resource-based challenges, to what extent do you think that those family hubs could be doing more to support that integration and what do you think that would look like?

There is a huge opportunity for family hubs to carry on as they have been evolving. Yes, Sure Start reinvented but perhaps with an additionality of really understanding this shared contribution to every child’s and family’s outcomes. For instance, we have been seeing some family hub activity where there has been a specifically organised bringing together of the library services, the health visiting colleagues on the same morning that is going to be badged as a communication morning where families can come and meet, go in, go out. You might come because you have been directed that you have a worry about your child, it might end up not being the right time to progress through the speech and language route but you can be immediately introduced to something helpful in the system. That requires those practitioners and the people who fund them to allow for that collaboration to happen—the iceberg model under the water—so that you walk in the child and family’s footsteps and they do not know all of that co-ordination has happened, they just experience what they need. There is something about not being tied into clinical pathways, which is another potential barrier. Alison mentioned the neurodevelopment assessment pathway, where children sometimes get parked on to a pathway because someone has identified, perhaps correctly, that that is what they ultimately might need. Everyone forgets that there is a load of opportunity that could be there that might not have that badge on it but is really, really important. The opportunity for people working together in the family hubs as they continue to develop, to plan that together in advance of families walking through the door, should absolutely be grasped.

I agree with that. I am not sure that I have anything to add.

Thank you very much, all three of you, for giving us your evidence this morning. I would say the same to you that I said to the previous panel. If there was anything that you did not feel that you were able to convey sufficiently to us because of the time pressure that we were under this morning, please feel free to write to us afterwards and we would welcome that. We are very grateful to you for your time this morning. Thank you very much.