Prof Ian Kessler of the NIHR Policy Research Unit in Health and Social Care Workforce is Professor of Public Policy and Management at King’s Business School. He introduces a new report from the Unit, scoping the demand and supply of NHS therapists for Children and Young People with Special Educational Needs and Disabilities.
This, the first of two blogs, focuses on the demand for, while the second discusses the supply of, therapists for Children and Young People with Special Educational Needs and Disabilities.
Context
The workforce delivering care and support for children and young people (CYP) with special educational needs and disabilities (SEND) is an elusive one. In part this elusiveness stems from the diffuse and fragmented nature of the workforce as CYP with SEND typically engage with a variety of services- education, health, social care and sometimes housing. Even drilling down into these discrete service segments, tying the SEND workforce down in terms of its size, skill mix, and capacity remains challenging. Take health as an example. CYP with SEND will have a range of developmental, physical, and mental health care needs, addressed by a variety of staff groups to be found in different clinical settings including: nursing in both community, acute and mental health settings, clinical consultants in a similar range of settings, GPs in primary care, and healthcare visitors in the community. Adding to the challenges is the fact that those in any one of these staff groups will have clients which include but are rarely limited to CYP with SEND. With policies often framed by and centred on ‘children and young people with SEND’ as the named client group [1], the hidden nature of the workforce caring for and supporting them becomes a real challenge in meaningfully delivering on the policy initiative.
At the end of 2023, the HSCWRU was asked by the Department of Health and Social Care (DHSC) to examine a key segment of the NHS England workforce addressing the needs of CYP with SEND: therapists. With a particular focus on speech and language therapists (SLT), occupational therapists (OT) and physiotherapists (PT), the study sought to map and provide a fuller picture of the NHS therapy workforce and its capacity to meet the demand for its services. As a recent House of Commons Education Committee report on SEND (2019:4) noted:
“We are seeing serious gaps in therapy provision (which) are letting down all pupils, but particularly those on SEN Support.” [2]
Such a concern might also be seen to have informed the government’s SEND Review, 2022, which stressed the need for DHSC to:
“Build a clearer picture of demand for support for children and young people with SEND from the therapy and diagnostic workforce.” [3]
Given the uncertainties surrounding the nature and scale of the workforce and indeed broader service capacity, the piece of work on CYP SEND therapies undertaken by the HSCWRU was a scoping exercise. Mainly focusing on the supply side of service delivery, but with an interest in the need and demand for therapies amongst CYP with SEND, the study sought to explore available secondary data sources, current policy initiatives and examples of current practice. At the same time, the study did generate primary data, 45 interviews being conducted, close to half (20), with therapy team leads, managers and therapy practitioners from different NHS healthcare providers, around a dozen (13) with national and regional programme and workforce leads. A series of interviews (9) was also undertaken with individuals from representative bodies: the Royal College of Speech and Language Therapists (RCSLT), the Royal College of Occupational Therapists (RCOT) and the Chartered Society of Physiotherapy (CSP). In a recently published report, the study’s findings are presented in three parts covering: service demand for therapies; their supply through the commissioning process and the associated provider workforces; and the work being undertaken by various bodies to better align the demand for and supply of therapies for CYP with SEND. In this blog, attention is focused on the demand and supply side parts of the report.
The Demand Side
Establishing the need for a therapy amongst children or young people with SEND is a heavily regulated process. A need only becomes a need-to-be-met within a publicly funded health and care system once it is recognised, referred and assessed according to specified criteria and deemed eligible, or not, for an intervention. In the main, the current regulation derives from the Children’s and Families Act, 2014[4], and its accompanying SEND Code of Practice[5]. These present a need or disability as arising where a child or young person has greater difficulty in learning or making use of educational facilities than their peers. In such circumstances additional SEN support, broadly conceived and discretionary, becomes available and at a certain threshold of need, an Education, Health, and Care Plan (EHCP), as managed by the local authority, becomes an option. Notionally running from the age of 2 to 25, the provision of an EHCP is a statutory requirement, its formulation and maintenance governed by a mandatory procedure. As a priority, the provision of the more loosely framed SEN support has unsurprisingly trailed in the wake of the statutory infrastructure underpinning the EHCP.
Department for Education data [6] [7] suggest the significant scale and growing incidence of additional support for school age children with SEND. Thus, 390,000 have an EHCP, a rise of around 150,00 over the last decade, while there are just over a million pupils with SEN support, an increase of around 200,00 over the same period. These data are less useful as an indicator of therapy requirements although speech and language needs, likely to require an therapy intervention, emerge as the most commonly cited for children with SEN support. As to how well the needs of CYP are being met, the most useful data source is provided by the Department of Health and Social Care (DHSC) on waiting times for different therapies [8]. In September 2023 66,000 CYP were on a community healthcare team waiting list for speech and language, therapy, although the numbers were much lower for occupational and physiotherapy. How many of these children and young people have special educational needs and disabilities, is less apparent from these data although many, if not most, will. Perhaps more profoundly it remains unclear whether these waits are for an assessment and or for a supportive intervention.
The increasing demand for therapies has been noted in a range of other studies [9] [10] [11] [12] and often seen as a Covid legacy. Our interviewees highlighted the restrictive living conditions, breaks in formal education, and the withering of social interaction associated with Covid as generating new or deepening existing conditions requiring therapy support. Moreover, pressure on services during this period limited access to therapies at this time, further exacerbating conditions.
The impact of Covid should not, however, distract from the longer term drivers of increasing demand for therapies for CYP with SEND. In part these have been related to a growing awareness and diagnosis of, for example, neurodivergent conditions. Many of the drivers have been rooted in the growing complexity of need reflected in: the socio-economic challenges faced by CPY with SEND, which complicate care and support needs; medical advances ensuring that CYP with SEND have thankfully been surviving but coming through with increasingly complex clinical needs, necessitating both early years and longer term support; and heavy procedural requirements as the administration, associated particularly with formulating and managing an EHCP, has grown. Service pressures also predate the pandemic, and interviewees highlighted the readiness of other parts of the heath and care system to routinely refer to specialist therapy services, as workload increases. For example, as a therapist interviewee noted:
“Health visiting partners are so stretched for staff that they send us more referrals as a universal offer, and we really should be a specialised service not for universal developmental delays. We’ve definitely felt a difference in referral rates.”
Prof Ian Kessler of the NIHR Policy Research Unit in Health and Social Care Workforce is Professor of Public Policy and Management at King’s Business School.
This is the first of two blogs. The second addresses the supply of therapists for Children and Young People with Special Educational Needs and Disabilities.
Read the report
Kessler, I., & Boaz, A. (2024) The Demand and Supply of Therapists for Children and Young People with Special Educational Needs and Disabilities: A Scoping Study. London: NIHR Policy Research Unit in Health and Social Care Workforce, The Policy Institute, King’s College London. https://doi.org/10.18742/pub01-181
KCL project page | KCL news item (15 May 2024)
Notes
[1] See for example SEND Review – right support, right place, right time (publishing.service.gov.uk)
[2] Special educational needs and disabilities (parliament.uk) See also Government Response to this report Special Educational Needs and Disabilities: Government Response to the Committee’s First Report of Session 2019 (parliament.uk)
[3] SEND Review – right support, right place, right time (publishing.service.gov.uk)
[4] Children and Families Act 2014 (legislation.gov.uk)
[5] SEND_Code_of_Practice_January_2015.pdf (publishing.service.gov.uk)
[6] Education, health and care plans, Reporting year 2023 – Explore education statistics – GOV.UK (explore-education-statistics.service.gov.uk)
[7] Special educational needs in England, Academic year 2022/23 – Explore education statistics – GOV.UK (explore-education-statistics.service.gov.uk)
[8] Statistics » Community Health Services Waiting Lists (england.nhs.uk)
[9] Left-Behind.pdf (disabledchildrenspartnership.org.uk)
[10] Children and young people with SEND disproportionately affected by pandemic – GOV.UK (www.gov.uk)
[11] RCOT_Children Survey report 2023_V4 (1).pdf
[12] See also Growing problems, in depth: The impact of Covid-19 on health care for children and young people in England | Nuffield Trust
Acknowledgements and disclaimer
This research is funded by the National Institute for Health and Care Research
(NIHR) Policy Research Programme, through the NIHR Policy Research Unit
in Health and Social Care Workforce, PR-PRU-1217-21002. The views
expressed are those of the authors and not necessarily those of the NIHR or the
Department of Health and Social Care. We are most grateful to all those who
contributed and participated in the study.