In Search of Hidden Healthcare Workforces: NHS Therapists for Children and Young People with Special Educational Needs and Disabilities (Part 2)

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 second of two blogs, focuses on the supply of, while the first addressed the demand for, therapists for children and young people with Special Educational Needs and Disabilities.

The Supply Side

Commissioning. While the capacity to address this increased demand rests in large part on the scale, structure, and capabilities of the therapy and, as already implied, the wider health and care workforce, the commissioning process for CPY with SEND, is pivotal. Commissioning determines the services available and at what level of resource, inevitably feeding through to determine the workforce required to provide them: to put it crudely, if a service is not commissioned, a workforce is not required. The close connection between service design and the workforce is apparent from various ‘good practice’ commissioning models [1]. These typically distinguish different levels of services linked to the nature of need and support, with implications for the requisite workforce: for example, accessible universal services delivered by a wider workforce; targeted services provided by registered therapists and their support co-workers; and specialist services the exclusive preserve of the registered therapist.

Whilst influential and widely used, such models are not easily implemented, confronting many years of commissioning, which have in turn embedded procedures and stakeholders with a vested interests in their maintenance. The result has been therapy commissioning arrangements for CYP with SEND which might generously be characterised as complex, and less generously, disordered. This has been reflected in uneven and patchy services provision, both in terms of geography and need. Given the range of service needs, core therapy commissioning has often been jointly undertaken by the local authority and the Integrated Care Board (ICB) (formerly Clinical Commissiong Groups), with interviewees in our study voicing various concerns about the process.

These concerns include: dated contracts with NHS providers, sometimes weakly monitored and as a consequence misaligned with service needs, resourcing  and workforce capacity; services in heavy demand simply being decommissioned; transition arrangements to adult services for young people over 19 with an EHCP, underdeveloped, with NHS therapy services typically not running beyond this age; a lack of clarity around the distribution of funding between the different therapies, particularly in block contracts.

The complexity of commissioning for therapies is deepened by commissioning activities beyond the core ICB to NHS provider process. Thus, resources permitting. special and mainstream schools sometimes directly commission therapy services themselves from NHS or independent providers. Similarly, the parents or carers of a CYP with SEND can also commission a service directly, while we even came across instances of NHS therapy providers sub-contracting activity to secure greater capacity.

Workforce. In the context of this commissioning regime, the NHS therapy workforce for CYP with SEND emerges as a nested workforce. It sits within a wider education and care workforce which provides much direct support in the classroom and domestic contexts; a broader healthcare workforce which addresses diverse clinical needs; and even more expansive NHS therapy workforce which involves support for CYP without as well as with SEND. This nesting is important in terms of establishing the capacity of the therapy workforce given the porosity of boundaries between the different workforces, and the scope for them to work in complementary and coordinated ways. At the same time, it makes the task of scoping of the NHS workforce for CYP with SEND a difficult process.

Established sources of workforce data provide at best a partial picture of the NHS therapy workforce for CYP with SEND:

  • The Health and Care Professional Council, the regulatory body for therapists, cites physiotherapists as the largest group with around 66,500 registrants in July 2023, followed by occupational therapists, with 43,600, and finally SLTs with 18,500[2]. However, such figures cover registered therapists beyond as well as within the NHS, and are not unpacked by clinical setting, provider type or client groups. Moreover, in not covering support workers they provide only limited insight into the capacity and scale of the therapy workforce.
  • NHS workforce data, covering NHS providers, do include therapy support workers, pointing to a combined registered and unregistered workforce of 27,00 whole time equivalent (WTE) physiotherapy workers 23,000 (WTE) occupational therapy workers, and 7,700 (WTE) speech and language theory workers[3]. Such published does not, however, include a breakdown of these staff groups by service team or setting, leaving it opaque as to how many of these therapy workers care and support for CYP, let alone CYP with SEND.
  • The membership data held professional association, which includes support worker, provides clues to workforce numbers, and it is noteworthy that all three associations have developed specialist sections which to varying degrees address the interest in children and young people with SEND. But published data on membership sections is not available, and of course more generally not all therapists are members of such professional associations despite their high membership density rates.

While precise data on the scale and nature of NHS, or indeed wider, therapy workforce for CYP with SEND currently remains limited, there has been no shortage of reports pointing to the challenges faced by this workforce in the context of increasing service demand. For example, in a January 2023 survey of around 330 managers of speech and language services across Britain, the Royal College of Speech & Language Therapists found an average 23%, vacancies rate for SLTs in children’s service, with 96% reporting recruitment of SLTs was ‘more’ or ‘much more’ difficult over the last three years. A 2021 survey of 339 occupational therapists, by the Royal College of Occupational Therapists found almost half (47%) reporting that they were not able to provide the level or type of occupational therapy input that children and young people needed, with over a third (39%) reporting ongoing issues with recruitment.

Our study confirmed the difficulties confronting the therapy workforce, coalescing around four main themes:

  • Patterns of Employment

There were indications of therapists seeking more flexible, portfolio forms of employment, which included but were not limited to working in the NHS. Indeed, more generally there were signs of movement away from the NHS towards employment in the independent and private sectors. In part this was driven by work-life balance issues, often a fallout from the pressures faced during the Covid period. Perhaps more tellingly it was also because some therapists felt their capacity to deliver hands-on therapies, central to their professional identity, was being undermined by the administrative overload of work in the NHS, not least connected to the EHCP process.

  • Recruitment and Retention

Staff shortages were raised as an issue across all therapy staff groups. Nonetheless, rather than being across-the-board, they were often seen as contingent on various factors: geography, particularly in areas where accomodation and living costs were high; professions with shortages amongst SLT presented as especially acute, and specialism, with certain therapy specialists for example in dysphagia especially difficult to find.

  • Training and Career Development

The absence of therapists in certain specialisms was in part related to training and career development options. More fundamentally issues were raised about the availability of undergraduate programmes in therapies from higher education institutes (HEI) in local catchment areas and the opportunities provided in HEI curriculum to focus therapies for children and young people. Even on qualifying the availability of rotational placement in children’s services was seen as patchy. More broadly career expectations were shaped in ways which perhaps understated the value and scope for progression into such services. As an interviewee noted:

“What we’re at risk of in the future is people coming through rotations and going, I never got that time in paediatrics.”

  • Staff well being

The well-being of NHS therapy workforce has already been touched upon as prompting moves from the NHS to other therapy providers. Indeed, the stresses and strains of work might also be seen to feed into broader staff retention challenges. While sharing the intensity of the pandemic with other NHS staff group, the disruption faced by therapists was particularly acute, with many being deployed from community to acute settings during this period. There have, however, been longer term trends at play, with caseloads in particular, increasing over a number of years with the rising service demand. Typically, caseloads are managed with sensitivity to ensure a mix in the complexity in the CYP supported. In general, however, caseloads were high, ranging from 50 to well over 100 children and young people. Indeed, while the provision of services to CPY with SEND is undoubtedly a distinctively rewarding activity, it can at times be a difficult and emotionally challenging workspace for staff: crowded with a diverse set of actors, occasionally in tension with one another, procedurally dense and affectively charged. As one interviewee noted:

“People can find the SEND world really combative.  Families and schools, their SENCOs (Special Educational Needs Co-ordinators), it can be really horrible, it’s aggressive and it’s not a nice place to be.  It’s not what people trained to do or signed up for. “


In the context of growing demand for NHS therapy services from children and young people with increasingly complex special educational needs and disabilities, scoping workforce capacity to deliver on this demand becomes crucial. The quality of life for these children and young people, their families, and indeed for the therapy workers delivering the care, is critically dependent on ensuring workforce capacity is adequate and fit for purpose. Our report suggests mapping this capacity remains difficult, with the therapy workforce- nested, fragmented, and diffuse- being elusive, perhaps hidden. This is not to overlook the attempts being made to map the workforce. Some of these attempts are set out in our report, one of the most striking being the use of job plans for speech and language therapy workers in various London boroughs to calculate direct care hours available to meet service demand. More generally, however, our report suggests that getting workforce capacity ‘right’ is tied to a more ordered, perhaps systems level, commissioning process, and to addressing some the current challenges faced by the NHS therapy workforce, centred on patterns of employment, recruitment and retention, training and development and worker well-being.

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 second of two blogs. The first addressed the demand for 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.

KCL project page | KCL news item (15 May 2024)


[1] About the framework : The Balanced System Pathway

[2] hcpc-annual-report-and-accounts-2021-22.pdf (

[3] Table based on data from: NHS Workforce Statistics, July 2023 Staff Group, Care Setting and Level.xlsx (

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.

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