HC 1048-III Health CommitteeWritten evidence from I CAN and The Communication Trust (PH 163)

1. Executive Summary

1.1 I CAN and the Communication Trust welcome the Health Select Committee’s inquiry into the future of public health. Speech, language and communication skills are fundamental for all children. Without effective intervention, speech, language and communication needs (SLCN) can have a detrimental impact on a child’s wider health and well being, literacy development, educational outcomes, emotional and social development and for those children with long term needs on mental health. However, from our experience, one of the biggest problems for those operating within the speech and language sector is the fragmented nature of commissioning and provision, most notably between Local Authorities and the NHS, but increasingly with schools as well. Collaboration will be ever more important for speech and language services given the greater commissioning powers granted to academies and free schools. Whilst we welcome the Government’s White Paper, Health Lives, Healthy People, and its focus on patient choice as well as improving the health of the poorest in society, we believe that more needs to be done to ensure early identification of SLCN as well as positive intervention for these vulnerable children through improved joint commissioning arrangements.

1.2 In this submission we have used our experience to highlight the following areas:

The need to ensure that the proposed NHS reforms do not result in a fragmentation of SLCN services, particularly given the need for collaboration between the health and education sectors.

To urge the Government to transfer responsibility for the coordination of the commissioning of children’s community health services, including speech and language therapy, to local authorities as proposed by the Education Select Committee in their report on Behaviour and Discipline.

The need to differentiate between the commissioning of low need, high incidence and high need, low incidence SLCN, with responsibility for commissioning for high need SLCN placed at the regional level, as proposed in the Department for Education’s Special Educational Needs Green Paper.

Concerns that there will be insufficient representation of children’s community health expertise on the proposed Health and Wellbeing Boards and the detrimental impact this could have on the joint commissioning of children’s health services.

The strong correlation between social disadvantage and poor communication skills and the need for commissioning arrangements to ensure that services are fair, enabling children and young people who do not find it easy to access services to find help through clear methods for referral to a specialist, as well as the need for targeted early intervention.

2. About I CAN

2.1 I CAN is the children’s communication charity. Our mission is to ensure no child who struggles to communicate is left out or left behind. Our vision is a world where all children and young people who struggle to communicate receive the help they need so that they can have a happy childhood, make progress at school and thrive as adults.

2.2 We do this through:

Increasing public awareness of the problems children face.

Giving expert advice to parents and families about what to look out for and what to do.

Providing assessments for children so that their families know what support will meet their needs.

Giving teachers and people working with children the skills to help children who struggle.

Campaigning to ensure children and families get a better deal.

2.3 At the very heart of I CAN are our special schools which give expert care and education to children with problems so severe their needs cannot be met elsewhere.

3. About The Communication Trust

3.1 The Communication Trust is a coalition organisation bringing together over 40 voluntary and community sector organisations with expertise in children’s speech, language and communication. Supported by the Department for Education, BT and other funders, The Communication Trust works to improve the speech, language and communication skills of children and young people and to ensure that children with speech, language and communication needs are better supported and included. The Communication Trust’s primary audience is members of the children’s workforce and those that set workforce policy and practice.

3.2 The Communication Trust has been appointed by the Government to deliver the National Year of Communication in 2011. The National Year aims to increase public understanding of how important it is for children and young people to develop good communication skills.

4. Background to Speech, Language and Communication Needs

4.1 Speech language and communication skills are the basis for other key life skills: learning, literacy, positive relationships and regulation of behaviour and emotions. Speaking and listening skills underpin pupil outcomes; young people with good communication skills have a wider range of life chances.

4.2 As many as 10% of children in the UK—over one million—have speech, language and communication needs, that require specialist help. This represents approximately three children in every classroom. Of this group, a large cohort—between 5–7% of the child population—have specific language impairment, meaning that they have difficulties with learning and using language that are not associated with factors such as general learning difficulties, or other conditions, such as cerebral palsy, hearing impairment or autistic spectrum disorders. A child with SLI might be bright, but struggle to understand the language used in the classroom, and thus struggle to attain and achieve.

4.3 Speech, language and communication needs can occur both in isolation and as the result of another disability, such as autism, Downs Syndrome or a hearing impairment.

4.4 Speech, language and communication needs are also strongly associated with mental health problems as well as other social emotional and behavioural difficulties.

4.5 Speech, language and communication is the most common type of need in primary-aged children with statements of special educational need. 26.5% all mainstream-educated, statemented children in this age group have speech, language and communication as their primary need.

4.6 I CAN’s Cost to the Nation report highlighted that speech, language and communication difficulties impact most severely on those children in deprived areas. In some parts of the UK, those with high unemployment and poor housing, the prevalence rate of SLCN rises. As many as 50% of five year olds are arriving at school without the speech and language they need to fully participate and achieve their potential at school. This figure rises to 80% in some areas. However, with the right support, these children have the potential to catch up with their peers.

4.7 There is evidence of a high incidence of communication difficulties (often unidentified) in those who are young offenders , , looked after children and those who have conduct disorder as well as other social emotional and behavioural difficulties. , In addition to this, limited language skills make it difficult for young people to access support or understand interventions.

4.8 Early identification is a preventative tool and mitigates the negative impact of speech, language and communication needs in terms of future health and well being and social disadvantage.

5. Commissioning of SLCN Services

5.1 Commissioning is the cornerstone of a responsive and effective health service. However, from our experience, one of the biggest problems for those operating within the speech and language sector is the fragmented nature of commissioning and provision, most notably between local authorities and the NHS, but increasingly with schools as well. Speech and language services require effective commissioning to come through from a number of areas. Speech and Language Therapists (SLTs) are employed by the NHS, while many interventions for children with SLCN take place in education or early years settings, demonstrating the need for cooperation across the education and health sectors. Therefore, a lack of coordination of services, particularly between health and education commissioners, can severely impact on the effectiveness of provision for children and families with SLCN.

5.2 In addition, collaboration will be ever more important for SLCN services given the greater commissioning powers granted to schools, particularly free schools and academies, under the Government’s education reforms, meaning that Headteachers will now be in a position to commission specialist support, such as speech and language services, as well as the opening up of the provider market of health services to the private and voluntary sectors. Therefore it will be important for the Government to ensure a seamless transition across commissioning bodies as well as effective joint working, not just within the health sector, but also between education and health commissioners, including schools and SureStart centres.

5.3 However, I CAN and the Communication Trust are concerned that proposals in the NHS Public Health White Paper could result in the fragmentation of the commissioning of children’s health services, particularly for SLCN services which are dependent on joint working. Arrangements need to be in place to ensure that commissioners are in a position to commission in the round for services provided by NHS and non-NHS agencies, whether local or regional, and to ensure that local commissioners do not simply “shunt” responsibility up the chain. It will also be important to develop effective communication channels with voluntary sector groups to ensure commissioners have an accurate picture of provision in their areas.

5.4 In addition, with the removal of the statutory duty for Children’s Trusts Boards as well as the duty on schools to cooperate with the local authority in regard to children’s well being, it will be important for alternative arrangements to be in place which enable SureStart centres and schools, particularly special schools, to engage with relevant local bodies in regard to children’s health services to facilitate adequate and joined up provision across various agencies.

5.5 While I CAN and the Communication Trust see the potential for the proposed GP consortia to help to focus provision on the holistic needs of the individual child and family, we are concerned that devolving commissioning powers down to this level will fragment services for those with low incidence, high need SLCN. Given the low occurrence of such need and the usually high cost of the intervention required, it will be both difficult and costly for GP consortia to commission specialised services at the local level, particularly if only one child in their commissioning area requires such intervention. We believe that it is important for commissioners to commission at sufficiently large volumes to ensure they have a good understanding of client needs and of what constitutes quality and productivity in provider services, particularly given that many children with high need SLCN are likely to have a range of additional SEN support needs. Therefore, we would propose that the responsibility for the commissioning of these services should take place at the regional level to facilitate better joint working for these most vulnerable children and allow for cost savings to be made.

5.6 I CAN and the Communication Trust welcome the recent proposals in the Department for Education’s SEN Green Paper which signal a move towards joined up provision via a holistic assessment of needs through new Education, Health and Social Care plans, but would like to note that this will again only be effective with greater coordination of commissioning across these sectors, particularly at the regional level for those with low incidence, high need. We would also like to ensure that these new plans place health and social care providers on a legal footing to match the statutory duties on local authorities in terms of educational resources.

5.7 In addition, evidence shows that only 9% of referrals to speech and language therapy services in London are currently made through GPs, demonstrating the complex web of referrals through education, social care and youth justice routes. Therefore it is important that all relevant agencies are involved in commissioning decisions, with the local authority acting as the lead, to ensure joined up provision services across.

5.8 Evidence demonstrates the strong correlation between social disadvantage and poor communication skills. I CAN and the Communication Trust welcome the focus of the Government’s health reforms on improving the health and wellbeing of the poorest in society and would like to highlight the vital role that the early identification of and effective intervention for underlying SLCN can have on child development and improved life chances. New commissioning arrangements must ensure commissioners work together to target provision to the most vulnerable in society, particularly through the early identification of need.

5.9 In addition, whilst we welcome the Government’s plans to expand the health visitor workforce, we are cautious about focusing solely on the role of health visitors in early identification (including identification of speech and language difficulties), as many young children, particularly those from poorer backgrounds, are not in contact with such early years professionals.

6. Next Steps

6.1 In our view there are a number of actions that should be taken to ensure adequate quality and provision of SLCN services can be achieved within the Government’s public health reforms.

6.2 As recommended by the Education Select Committee’s recent report on Behaviour and Discipline, I CAN and the Communication Trust would like to see the transfer of responsibility for budgets and commissioning of all children’s community health services (including speech therapy services) to local authorities in order to provide a more streamlined service to young people and their families, bridging the gap between “specialist” and “non-specialist” interventions. We urge the Government to take forward this recommendation. The idea of locating responsibility for commissioning children’s community health services within local authority children’s services is not new, and is worth revisiting given the commissioner/provider split that has recently been achieved, meaning that staff in childrens’ community health services can remain employed by NHS provider organisations, with only the specification of the services they provide moving to the local authority.

6.3 GP consortia will also need to commission services when the access point is through them; however, unless the child’s needs are low incidence, high need then the referral should be to the local authority, who will be expected to work closely with GP consortia.

6.4 However, for low incidence, high need SLCN, we believe that commissioning should sit at the regional level, ie those defined as falling within the Specialised Services National Definitions Set. These specialised services include communication aid services, defined as including “expert assessment, followed by demonstration, trial and provision of appropriate electronic and non-electronic communication devices, ie augmentative and alternative communication systems (AAC), user training, equipment maintenance, on-going support and periodic review.” (4.3, SSNDS Definition No 5, page 5).We would propose that the commissioning of these services is conducted by the NHS and via the regional arrangements established in due course by the NHS Commissioning Board. The Department for Education’s Special Educational Needs Green Paper proposed that the commissioning of highly specialised services such as ACC become a core responsibility of the NHS Commissioning Board, and we welcome this proposal.

6.5 I CAN and the Communication Trust believes that the new Health and Wellbeing Boards are best placed to ensure integrated working between commissioners of NHS, public health and social care services, but would urge the Government to ensure they include adequate expertise in children’s community health services to enable effective joint commissioning, particularly for speech and language services. In addition, Health and Wellbeing Boards ought to develop effective communication channels with voluntary sector groups to ensure they have a picture of commissioning and provision in their areas. The recently published Special Educational Needs Green Paper also noted that Health and Wellbeing Boards will need to consider how the needs of children and young people with SEN can best be taken into account through the Joint Strategic Needs Assessment.

6.6 However, schools and local authorities will also need to work closely together to commission for high incidence SLCN and we would like to see a duty placed on Health and Wellbeing Boards to ensure integrated working between both health and school commissioners. We also urge the Government to consider examining how NHS technology solutions could be applied to speech and language, in particular joining up commissioners in health and education with providers. If accessible by parents in a secure manner then parents will also be able to interact with both commissioners and providers and engage in meaningful dialogue with the decisions being made on their child’s behalf. There is already a precedent for this within healthcare through developments in the Summary Care Record and we would urge the Government to consider its extension to education commissioners.

6.7 The Special Educational Needs Green Paper also noted the Department of Health will consider how the needs of all children and young people, including those with SEN, can best be taken into account through guidelines and standards issued by NICE in regard to commissioning. I CAN and the Communication Trust welcome this move and would also like to see the NHS Commissioning Board develop commissioning guidance for SLCN services, and that NICE should be tasked with producing Quality Standards for speech and language under its expanded role to ensure minimal levels of service quality.

6.8 Given that almost 50% of children from disadvantaged communities have SLCN, which can lead to other health and wellbeing issues, we would like to see provision targeted, particularly through early identification. Frank Field MP’s recent Independent Review on Poverty and Life Chances recommended the introduction of Life Chances Indicators to measure children's cognitive, physical and emotional development at the ages of three and five to allow for effective intervention, with the cognitive indicator including a specific measurement of speech and language development.

6.9 We would like to see the forthcoming Foundation Years Strategy set out in more detail the plans for universal screening for SLCN at 2–2½ (to tie into the Healthy Child Programme check) as recommended in Dame Clare Tickell’s Review of the Early Years Foundation Stage and Graham Allen’s review of Early Intervention. We would urge the Government to take forward these recommendations.

6.10 We would also like to see more targeted screening for young people with identified risk factors, for example, a 10 point differential between verbal and non-verbal on CATs tests, behaviour, reading age etc. In addition, we encourage the Government to look at ways of supporting parents to assess need via an initial screening tool. This need not be onerous and should always come with the advice that formal diagnosis should be sought but may help reassure parents, many of whom struggle to understand why their child displays the characteristics which indicate SLCN but are unable to get a formal diagnosis.

6.11 In addition, we would like to ensure effective mechanisms are in place to hold commissioners to account on their provision of services for children with special education needs, including a specific duty in regard to speech and language services, via the new Healthwatch organisations.

6.12 I CAN and the Communication Trust believe the voluntary and community sectors can contribute significantly to local approaches to improve public health. There are a number of actions that should be taken to address SLCN amongst children and which we would be able to help deliver including:

Provide tools to help the wider children’s workforce including GP consortia and health visitors to identify and assess speech language and communication needs (SLCN) to help identify areas for development.

Identify clear triggers for referral for specialist help with SLCN.

The provision of that specialist help.

Advice on how speech and language therapists form part of the multi disciplinary health team that works effectively with children and young people.

June 2011

Prepared 28th November 2011