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Health & Social Care Needs Assessment

Worcestershire

Health and Well-being Board

Joint Strategic Needs Assessment (JSNA)

Joint Commissioning Services to Children and Young People with Speech, Language & Communication Needs

Needs Assessment and Service Mapping Report

June 2015

www.worcestershire.gov.uk/jsna

http://www.worcestershire.gov.uk/jsna

http://www.worcestershire.gov.uk/jsna

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Document details

Version: 1.1

Version date: February 2016

Status: FINAL

Source file location: Contact [email protected] for details

Review Date:

mailto:[email protected]

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Contents

JOINT COMMISSIONING SERVICES TO CHILDREN AND YOUNG PEOPLE WITH SPEECH, LANGUAGE & COMMUNICATION NEEDS NEEDS ASSESSMENT AND SERVICE MAPPING REPORT JUNE 2015 .......................... 1

WWW.WORCESTERSHIRE.GOV.UK/JSNA .......................................................................................................... 1

EXECUTIVE SUMMARY .................................................................................................................... 6 1. INTRODUCTION .................................................................................................................... 10 2. SCOPE OF THE NEEDS ASSESSMENT ........................................................................................... 10

2.1 Population group(s) of interest ........................................................................................................ 11 3. POPULATION TRENDS AND NEEDS ............................................................................................ 11

3.1 Pattern of need at a national level................................................................................................... 11 3.2 Local Population from National Prevalence Data ............................................................................ 14 3.3 Local Population from Local Service Data ........................................................................................ 14 3.4 Population Increase ......................................................................................................................... 16 3.5 Evidence of Best Practice ................................................................................................................. 19 3.6 Current Local Services ...................................................................................................................... 21 3.7 SLT waiting times ............................................................................................................................. 34 3.8 Reasons for discharge ...................................................................................................................... 34 3.9 SEN Data .......................................................................................................................................... 35 3.10 IMPACT ON EDUCATIONAL ACHIEVEMENT ..................................................................................... 40

4. OUTCOMES ASSESSMENT ....................................................................................................... 43 4.1 The Early Help Needs Assessment Report ........................................................................................ 43 4.2 Evidence of successful Speech and Language interventions and models of care. ............................ 43 4.3 Outcome / symptom specific evidence............................................................................................. 44

5. POLICY AND FINANCIAL CONTEXT ............................................................................................. 44 5.1 Statutory duties................................................................................................................................ 44 5.2 Budget .............................................................................................................................................. 45

6. ASSESSMENT OF CURRENT SERVICES ......................................................................................... 46 6.1 SCLN Service and Youth Offending ................................................................................................... 48

7. ASPIRATIONS OF THE POPULATION ........................................................................................... 49 7.1 Feedback from Early Years settings ................................................................................................. 49 7.2 Feedback from Special Schools ........................................................................................................ 51 7.3 Focus Groups with Parent Carers ..................................................................................................... 52 7.4 Stakeholder's Engagement through Survey ..................................................................................... 54

8. ALTERNATIVE MODELS OF SERVICE PROVISION ............................................................................ 57 8.1 Best practice..................................................................................................................................... 57 8.2 Snapshot of models from some other local authorities ................................................................... 59

9. CONCLUSION AND RECOMMENDATIONS .................................................................................... 61 10. OUTCOMES EXPECTED ........................................................................................................... 62

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List of Figures

Figure 1: Prevalence rate of children and young people with SLCN 12 Figure 2: Referral rates to Speech & Language Services 0-4 years old by IMS 2010-13 14 Figure 3: Future need for 0-5 SLCN 14 Figure 4: Percentage of Primary School Pupils with Statements of Special Educational Needs (SEN) or at School Action Plus, by Main Type of Need – Worcestershire, West Midlands and England 15 Figure 5: Percentage of Primary School Pupils with Statements of Special Educational Needs (SEN) or at School Action Plus by Main Type of Need – Worcestershire and 2014 Statistical Neighbours 15 Figure 6: Population projection – Worcestershire 16 Figure 7: Prevalence rates - Pupils at SAP or with a statement of SEN - rate per 1,000 pupils - Speech, Language and Communication Needs 16 Figure 8: Estimated number of children resident in Worcestershire with a SAP or statement of SEN - Speech, Language and Communication Needs 16 Figure 9: Proportion of SLCN among SEN population, 2012-15 17 Figure 10: Percentage of children achieving 6 or more within Communication, Language & Literacy Skills (CLL EYFS Profile) – Worcestershire compared to National percentages over the past 5 years 18 Figure 11. Children achievement in Communication, Language & Literacy 18 Figure 12. Percentage of children achieving minimum expected level on individual Early Learning Goals of the COM (Communication and Language) and LIT (Literacy)- 2014 19 Figure 13: The Balanced System © Gascoigne 2008 20 Figure 14: Preschool Speech and Language Therapy Service 22 Figure 15: School Age Speech and Language Therapy Service 23 Figure 16. Average retests for Worcestershire schools 24 Figure 17: Number of new referrals to service 26 Figure 18: Number of new referrals to service by district by team 27 Figure 19: Referral Rates 27 Figure 20: Total open referrals 28 Figure 21: Total open referrals by team 28 Figure 22: Open referrals by team (mid-June 2015) 28 Figure 23: Total referrals by age (mid-June 2015) 28 Figure 24: Age of Referral to Speech & Language Therapy Services 29 Figure 25: Source and age referral to SLT Services 2010-15 29 Figure 26: Proportion of sources of referral, 2010-15 30 Figure 27: Proportion of age at referral, 2010 30 Figure 28: Health Visitor Referral to Speech & Language Therapy Services 31 Figure 29: Health Visitor Referral to Speech & Language Therapy Services 31 Figure 30: Educational establishment referral 32 Figure 31: Referrals to Pre-School Forum by Need 32 Figure 32: Referrals to Pre-School Forum by Need 33 Figure 33: Caseloads by district 33 Figure 34: Paediatric S&LT Waiting Time, Mar 2012 – Jan 2015 34 Figure 35: Reasons for discharge, 2011-14 35 Figure 36: Reasons for discharge by age group, 2011-14 35 Figure 37: Number of children with SLCN identified as primary educational need 36 Figure 38: Proportion of SLCN as primary need by district 36 Figure 39: Average proportion of Worcestershire children with SEN Primary Need for 2012-15 37 Figure 40: Educational placement for children with SLCN listed as their primary need 38 Figure 41: SLCN prevalence across year groups 2015 38 Figure 42: Number of children by Primary Educational Need 2012-13 39 Figure 43: Number of children by Primary Educational Need 2013-14 39

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Figure 44: Number of children by Primary Educational Need 2014-15 39 Figure 45: SLCN prevalent rate in preschool SEN population 39 Figure 46: School Readiness, 2012-13 40 Figure 47: 2014 EYFSP - Communication and Language - % of children achieving at least expecting 41 Figure 48: Percentage of pupils achieving Level 4+ KS2 2014 42 Figure 49: Percentage of pupils achieving L4+ in Reading, Writing & Maths 42 Figure 50: Funding for SLCN 45 Figure 51: Action plan from SLCN service redesign, 2010 46 Figure 52: Numbers of Young Offenders in Worcestershire over the last 4 years. 49 Figure 53: Feedback from Early Years settings 49 Figure 54: Survey responses 55 Figure 55: Stakeholder engagement suggested recommendations 57 Figure 56: Comparison with statistical neighbours 61

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Speech, Language & Communication Needs Needs Assessment & Service Mapping

Project/Commissioning Manager: Ezekiel Obileye

Project Sponsor: Hannah Needham

Clinical lead: Jacqui Woodcock

Strategic priority: Children and Young People are helped at an early stage (Worcestershire's Children and Young People's Plan, 2014-17)

Care pathway: Worcestershire's SLCN Pathway

Date: 29/02/2016

Executive Summary

The aim of this needs assessment is to outline and examine the needs of children and young people in Worcestershire and consider how the needs can continue to be efficiently met for improved outcomes through commissioning of a model of service provision that is fit for purpose. The needs assessment report presents the population data, considers best practice and stakeholders' feedback, evaluate current service and identify any gaps; in order to make recommendations for the design of future service that will improve outcomes.

The needs assessment has included engagement with key stakeholders, including families.

Feedback from Early Years providers and Schools:

Waiting Times – There was an emphasis on the need to improve waiting times when initial referrals are made to the service.

Training – There was a need for increased training opportunities at more accessible times, such as evenings.

SLT Visits – Visits by speech and language therapists need to be more frequent, there needs to be more follow up appointments in the setting where the child spends a great deal of time. In some cases groups stated that a therapist had never been to their setting.

Feedback from Special Schools on the current service delivery arrangements:

Clarity for schools (particularly special schools) about the core offer from the commissioned service.

Schools to be part of on-going Performance Management of the SALT service.

Feedback from Parents

Overwhelmingly all parents agreed that the involvement of the family is key.

The majority of parent/carers surveyed had accessed SALT. Over 60% of felt that it was Quite Easy or Very Easy to access the SALT service. The proportion finding the process difficult seems to have declined in recent years.

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Parent/carers are notably positive about the following aspects within the SALT service, with a notably higher proportion rating the service Good or Very Good than rating the service Poor or Very Poor:-

The location of clinics / appointment centres

The sensitivity of the service towards their child's cultural and religious needs

The times of clinics / appointments

Support and advice from your child's early years setting / school

Quotes from parents/carers included:

"I've had excellent support from my therapist in the past – with update phone calls and regular text messages. I felt included and knew what support my child was getting in school".

"I have no idea who my child's therapist is, or how many times they are seen in school. I get targets twice a year, in a brown envelope, with no explanation – I don't feel involved or included, or have any idea how I can help at home'. 'I had to ring the (special) school to find out what therapy my child was receiving and how often"

Suggested areas for improvement included:

clear exit strategies

more transparency and flexibility of the service,

improved communication and contact between the initial referral and receiving the service, and

time to enable therapists to meet/talk with the parents directly.

The need for speech, language and communication specialist support – A summary

There has been an increase in referrals over the past 5 years, and this is likely to be attributed to the workforce training delivered by therapists to skill up health visitors, early years settings and schools to identify issues earlier. Also the Talking Walk-in service (drop in) promotes accessibility for SALT advice for the under 5's and this may also have impacted on referrals.

Evidence of early identification and Health Visitor training appears to be working (data shows that health visitors are referring children at an earlier age, year on year).

Average waiting times have remained steady between 6 and 9 weeks, increasing slightly from January 2015 but on average being 9 weeks between April 2013 and April 2015. The overall average of 9 weeks is too high. It has been rare for children to wait over 18 weeks to be seen, except since February 2015 due to unprecedented staff vacancies in the South of the County, which is currently being addressed.

There are a higher number of referrals from deprived areas, and this trend is likely to continue.

Communication, language and literacy scores (school readiness) have been increasing year on year so the direction is good, however, Worcestershire is still performing much lower than statistical neighbours.

Training of all professionals (e.g. health visitors, nursery staff, school staff) was rated by 75% of respondents in a local survey, to be the best way to improve Speech and language.

Youth offending figures from Nov 2010 to Nov 2011 show there were 367 young offenders. If the predicted incidence rate of 60% of young offenders experiencing SLCN is applied, this would mean there were 220

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young offenders in need of support with communication. Locally, there is not an accurate picture of the number of young offenders who may have SLCN because the current YOS assessment does not currently provide information that will trigger a referral. The introduction of the Comprehensive Health Assessment Tool (CHAT) within YOS in the near future will help to address this gap.

The current cost of the SALT service, which includes the prevention and early intervention part of the service, appears to be comparable to other statistical neighbours with similar populations; however, limited benchmarking data was available to commissioners.

Early Intervention for SALT – A Summary

Initial conclusions are that the Talking Walk-in service (drop in element) is well used, of good quality, provides choice for families to attend at a convenient location and time, and offers early intervention in line with best practice.

Parents do travel to children's centres to access a drop in session, and don't necessarily attend their local children's centre.

Parents want tips and activities available online to support their children communication needs.

A workforce programme to skill up early year's settings has been successful in increasing awareness and confidence of identifying language issues within settings. Every Child A Talker (ECAT) is still used within 77% of settings of those trained in Waves 1 and 2 (which began in September 2008).

Despite evidence of success, the current pace of the ECAT programme is relatively slow as it has taken six years to cover just under 50% of settings.

There is no statistically significant difference between the effectiveness of using trained parents and clinicians in administering interventions, so either can be used successfully.

Evidence also supports the use of normal language peers in interventions as language models for children with language impairment.

Future Population

Demand for support with speech, language and communication is projected to slightly increase in the next 5 years using prevalence data (increase of around 63 children). There are higher numbers of referrals from deprived areas, and with the birth rate due to increase in areas of deprivation, the need for speech and language in those areas is likely to increase, on top of the general projections.

Recommendations:

1. The commissioning of the prevention and early intervention element of the SALT service should be revised to ensure better use of early intervention investment and improved integration with wider early intervention/early help services.

2. There should be a strong focus on coverage across early year's settings (considering designs around language classes, workforce development and timely access to a service or advice and support) as evidence has shown the need for a focus on 0-5's, early intervention.

3. The revised SALT service specification will address an improvement in average waiting times and outcomes measures. This will consider a specific KPI around average waiting times. The design phase will consider models for timely assessment and intervention.

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4. Make clear to schools and other settings the level of service that they can expect from the

commissioned speech and language service. Also outline additional support over and above the core service that is available for schools and settings to purchase.

5. Join up commissioning with WCC education commissioners in order to utilise all funding in the most efficient manner, and deliver the SEN Reforms effectively.

6. Implement the use of the CHAT assessment toolkit within YOS for every young offender, to be able to clearly identify communication needs. Better recording from the CHAT assessment data will help to identify needs earlier. The new service specification will outline the approach between the Youth Offending service and the Speech and Language Therapy service, with a robust KPI, to achieve better outcomes for Youth Offenders with speech, languge and communication needs.

7. Train health visitors to be able to undertake further screening and early intervention to avoid unnecessary attendance at drop in sessions and escalation to specialist interventions. This would build on existing training that has taken place. Ensure that refresher training for health visitors is available, due to the positive impact that SALT training appears to have produced and ensure that training continues to be avaialable

8. As a result of the analysis of postcodes of Talking Walk-in attendees, drop-ins at universal children's centres, and some targeted settings should cease. It is recommended that the alternative provision includes information, advice and guidance. The additional time available at the end of clinics within these sites can then be utilised flexibly to address pressures in the service.

9. Make available a range of information for families via a website and other mediums to promote prevention and early intervention.

10. At the time of writing this Speech and Language Needs Assessment, a review of the Neuro-Developmental Pathway has commenced and the findings of this may inform the design of the future Speech and Language therapy service.

11. The design phase should include families and stakeholders.

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FULL REPORT

1. Introduction

The aim of this needs assessment is to outline and examine the needs of children and young people in Worcestershire, and consider how the needs are being met by the current speech and language therapy service. The needs assessment will identify any gaps in provision, with a view to make recommendations and design service provision that will improve outcomes.

The Speech and Language Therapy Service provides universal information, advice and guidance to all schools, settings and parents and carers to support speech, language and communication development in children and young people. The service provides intervention and support at the earliest opportunity and in the most appropriate environment. Specialist and targeted therapy provision is provided in a timely manner, however there is a high emphasis on skilling up the wider workforce to support early identification and intervention, making best use of available resources.

Speech and language therapists support children with language difficulties and help them to learn in school, yet speech and language therapy services are part of the health service and not part of education. Because of the importance of language in education and because of the increasing numbers of children with language difficulties, speech and language therapy services have been trying to find ways of working more closely with education colleagues (Lisa Thistleton, University of Birmingham Thesis, 2008).

Speech and Language skills are crucial, especially for children as they learn to interact socially and emotionally as well as academically. Speech and Language difficulties can have a detrimental effect on a child’s development and can impact on their behaviour, academic progress and employability.

Research from the Better Communication Research Programme demonstrates a range of interventions can be used to improve speech and language skills in children and young people. For all children, good universal provision is needed to develop speech and language skills that contribute to learning, literacy and good social skills. Some children will need targeted interventions to address short term difficulties. Other children will need specialist interventions that may have a focus on speech, language development or communication.

2. Scope of the Needs Assessment

This Needs Assessment and Service Mapping project considers speech and language therapy service provision for the following age groups across universal, targeted and specialist provision :-

Early years (all children under 5 years).

School Age (children and young people 5 – 19 years).

The needs assessment will inform services for those involved in the Youth Justice System as it relates to speech and language needs. This has become necessary by the recommendation in the recent YOS inspection report about the need to ensure access to SCLN for young offenders. It stresses the importance of early identification and process of addressing needs is key to achieving outcomes. This was also outlined in Nacro's paper: Speech, language and communication difficulties – Young people in trouble with the law (April, 2011). It stated that:

'Whilst not directly focused on those with speech, language and communication needs, Lord Bradley’s 2009 review of people with learning disabilities and mental health problems in the criminal justice system

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stressed the importance of early identification, intervention and support at various stages in the criminal justice process: arrest and prosecution; appearance in court; placement on a community order; placement in secure accommodation; and during resettlement.'

This needs assessment also links to the Early Help needs assessment, which includes non-specialist speech and language therapy needs and its provision through early intervention within the wider Prevention and Intervention Strategy. In addition, this needs assessment will look at the needs assessment that has been completed around specialist language classes.

2.1 Population group(s) of interest

Early years (all children under 5 years)

School Age (children and young people 5 – 19 years)

Who can be viewed in three broad sub groups:

Primary needs – language difficulties in the absence of any identified neurodevelopmental or social cause.

Secondary needs – SLCN in association with another need, i.e. a cognitive, sensory or physical impairment.

Needs linked to socio-economic disadvantage - some children, particularly those from socio-economically disadvantaged populations, can have speech and language skills that are significantly lower than those of other children of the same age. Given the right support, these children are likely to catch up with their peers.

2.1.1 Key Risks for the group and need for a review

Research has shown that children with Special Educational Needs and Disabilities with the primary need of SLCN perform poorly compared to their peers. Due to the national research evidencing progress of many pupils with SLCN receiving the right interventions early in their childhood, without an efficient service of early identification and intervention that is fit for purpose, improvement in the academic attainment of this cohort will fall behind and/or jeopardised.

There has been;

an increase in the number of children and young people including those in nursery and reception classes who have speech and language needs.

pressure on the service due to increased referrals.

concerns about partnership working especially with the Special Schools. These need attention as suggested by Wright and Kersner (1998) who highlighted that support for children with language needs would be most effective when offered, not in isolation, but in the context of the child’s social and educational environment.

3. Population Trends and Needs

3.1 Pattern of need at a national level

It is estimated that one in 10 children in the UK have a persistent Speech Language and Communication Need (SLCN) and 7% have a speech and language impairment (SLI). SLCN are the most common type of special educational need (SEN) in 4-11 year old children, and numbers are rising; whether because of real growth or better identification.

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Figure 1: Prevalence rate of children and young people with SLCN

Source: I CAN Talk Series (9), 2011

The estimated population of 0-19 year olds living in Worcestershire is 128,200 which is equivalent to 22.6% of the total population. The estimated population of 0-18 year olds living in the county is 121,779.

The numbers of children diagnosed with Autistic Spectrum Disorder is increasing. Autism was once thought to be an uncommon developmental disorder, but recent studies have reported increased prevalence and the condition is now thought to occur in at least 1% of children (NICE, 2014). The majority of children on the ASD spectrum will have a degree of communication difficulty.

Evidence shows that children from lower socio-demographic backgrounds tend to have poorer language skills when they start school. According to the Communication Trust, more than half of children starting nursery school in socially deprived areas of England have delayed language; while their general cognitive abilities are in the average range for their age, their language skills are well behind.

At a population level speech, language and communication needs are associated with a number of factors:

Gender is associated with the greatest increase in risk for both SLCN and ASD, with boys overrepresented relative to girls with a ratio of 2.5:1 for SLCN and over 6:1 for ASD.

Birth season effects are strong for SLCN but not ASD. Pupils who are summer born (May-August) and therefore the youngest within the year group are 1.65 times more likely to have identified SLCN than autumn born (September-December) students.

There is a strong social gradient for SLCN, with the odds of having identified SLCN being 2.3 times greater for pupils entitled to free school meals (FSM) and living in more deprived neighbourhoods. For ASD the socio-economic gradient is less strong but still important (the odds are 1.63 greater for pupils entitled to FSM).

Having English as an additional language is strongly associated with being designated as having SLCN, but not ASD.

There is a substantial reduction in the proportion of pupils with SLCN at School Action Plus over Key Stages 1 and 2, suggesting that for many pupils SLCN identified in the early years of primary school are temporary and transient. This applies to both those pupils for whom English is an additional language and those for whom it is their first language.

Both SLCN and ASD are associated with low achievement, but pupils with SLCN are lower achieving compared to those with ASD.

There is a pronounced variation across ethnicities for both SLCN and ASD:

o A pupil of Asian heritage is half as likely to have ASD as a White British pupil;

o A Black pupil is almost twice as likely to have SLCN as a White British pupil.

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Speech impairment can be caused by medical needs such as cleft lip and palate or hearing difficulties. Learning difficulties result in delayed development of the understanding of language and the expression of language.

Children with Autistic Spectrum Disorders have communication needs on the social use of language but tend to have better structural language skills than other children with language impairment.

3.1.1 Early identification

The Bercow Report (2008) recommended early identification of SLCN as key to the development of the person. According to Roulstone et al. (2011), children’s language development at the age of 2 years can predict school readiness at age 4.

Many children slip through the net and are not picked up early enough. Forty per cent of 7 to 14 year olds referred to child psychiatric services had a language impairment that had never been identified.

3.1.2 Impact of language and Communication Difficulties

Speech, language and communication difficulties have an impact on children’s educational attainment, behaviour, wellbeing, employability and inequalities (Office of Communication Champion, 2011).

Early speech, language and communication difficulties are a very significant predictor of later literacy difficulties (Snowling et al, 2010). Vocabulary at age 5 is a very strong predictor of the qualifications achieved at school leaving age and beyond (Feinstein and Duckworth, 2006). Speech and language skills are good predictors of educational attainment. Only 10% of children with SLCN achieve 5 good GCSEs including English and maths.

Speech and language skills also predict behaviour and wellbeing. Good language skills act as a ‘protective factor’ which reduces the likelihood of poor school attendance, truancy, delinquency and substance misuse (Snow, 2000). Two thirds of 7‐14 year olds with serious behaviour problems have language impairment (Cohen et al, 1998).

Two thirds of young offenders have speech, language and communication difficulties, but only 5% of these cases had been identified prior to an offence being committed (Bryan, 2008).

Victims of bullying and those who are both bullies and victims are more likely to have had limited early language skills than other children (Gutman and Brown, 2008).

Without effective help a third of children with speech, language and communication difficulties will need treatment for mental health problems (Clegg et al, 1999).

The changing jobs market means that communication skills, along with influencing skills, computing skills and literacy skills, have shown the greatest increase in employer‐rated importance over the last 10 years (UK Commission for Employment and Skills, 2009). 47% of employers in England report difficulty in finding employees with an appropriate level of oral communication skills (UK Commission for Employment and Skills, 2009).

Language development has a large impact on life chances. On average a toddler from a family on welfare will hear around 600 words per hour, with a ratio of two prohibitions (‘stop that’, ‘get down off there’) to one encouraging comment. A child from a professional family will hear over 2000 words per hour, with a ratio of six encouraging comments to one negative (Hart and Risley, 2003).

Low income children lag their middle income counterparts at school entry by nearly one year in vocabulary. The gap in language is very much larger than gaps in other cognitive skills (Waldfogel and Washbrook,

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2010). Vocabulary at age 5 has been found to be the best predictor (from a range of measures at age 5 and 10) of whether children who experienced social deprivation in childhood were able to ‘buck the trend’ and escape poverty in later adult life (Blanden, 2006).

3.2 Local Population from National Prevalence Data

From the Early Help Needs Assessment Report, an estimate of the number of children and young people in Worcestershire with speech, language and communication (SLCN) needs is provided by the Department for Education in terms of a rate per thousand pupils. In Worcestershire the rate is 44.4/000 in primary schools. The rate is lower in secondary schools in Worcestershire at 12.9/000 pupils. This demonstrates the importance of identifying and treating speech, language and communication difficulties as early as possible, preferably before the child goes to school. The two year developmental check-up provided by Health Visitors provides the ideal opportunity for referral to SALT services. The graph below also clearly depicts a social gradient in referral rates to speech and language services.

Figure 2: Referral rates to Speech & Language Services 0-4 years old by IMS 2010-13

Source: WCC PH Annual Report

The Early Help Needs Assessment has estimated the future need for children aged 0-5 with SLCN.

Figure 3: Future need for 0-5 SLCN

Year 2013 2014 2015 2016 2017 2018 2019 2020

Population aged 0-5 31,808 31,931 32,085 32,008 31,854 31,811 31,750 31,678

Estimated need 1,412 1,418 1,425 1,421 1,414 1,412 1,410 1,406

Source: ONS Census 2011 based population projections and DfE estimated prevalence rate per 1000 (44.4/1000)

The prevalence in primary schools, by 2020, is projected to be 1799 and 453 in Secondary.

3.3 Local Population from Local Service Data

In Worcestershire, speech, language and communication needs are the most common type of need, both in absolute terms and also as a percentage of all SEN. The figures for the latter for Worcestershire far exceed

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the national and regional percentages. More than 40 percent of those with SEN in Worcestershire have speech, language and communications as their main need, equivalent to nearly 2,000 pupils.

Figure 4: Percentage of Primary School Pupils with Statements of Special Educational Needs (SEN) or at School Action Plus, by Main Type of Need – Worcestershire, West Midlands and England

Comparison with 2014 statistical neighbours confirms that speech, language and communication need is of high prevalence in Worcestershire's primary schools. Worcestershire has the highest number (1,982) and percentage (41.0%) of SEN with this type of need compared with statistical neighbours in 2014 (approximately ten percentage points higher than the neighbour average). There are also significant numbers of pupils (and proportions of SEN) with moderate learning difficulties and behavioural, emotional and social needs although these are in line with statistical neighbours. The chart shows the number of each type of SEN in Worcestershire's primary schools and the percentage of the overall number of SEN, along with the 2014 statistical neighbours.

Figure 5: Percentage of Primary School Pupils with Statements of Special Educational Needs (SEN) or at School Action Plus by Main Type of Need – Worcestershire and 2014 Statistical Neighbours

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In secondary schools in Worcestershire1, behaviour, emotional and social difficulties are the most common type of special educational need, which is broadly in line with the regional and national picture. Specific learning difficulties and moderate learning difficulties are also common in Worcestershire but no more so than in the West Midlands or England. Speech, language and communication needs are higher than national or regional charts, albeit not on the same scale as for primary schools.

3.4 Population Increase

Figure 6: Population projection – Worcestershire

Year 2012 2013 2014 2015 2016 2017 2018 2019 2020

0-4 31,488 31,808 31,515 31,646 31,531 31,359 31,357 31,306 31,255

5-11 42,741 43,520 43,906 44,444 45,002 45,452 45,708 45,782 45,820

12-16 33,428 32,681 31,674 30,905 30,684 30,717 31,057 31,691 32,374

Source: mid-2012 and mid-2013 ONS estimates, and mid-2012-based ONS population projections

Figure 7: Prevalence rates - Pupils at SAP or with a statement of SEN - rate per 1,000 pupils - Speech, Language and Communication Needs

5-11 (primary) 44.4 44.4 44.4 44.4 44.4 44.4 44.4 44.4 44.4

12-16 (secondary) 12.9 12.9 12.9 12.9 12.9 12.9 12.9 12.9 12.9

Source: Department of Education, 2013

Figure 8: Estimated number of children resident in Worcestershire with a SAP or statement of SEN - Speech, Language and Communication Needs

Year 2012 2013 2014 2015 2016 2017 2018 2019 2020

0-4* 1,398 1,412 1,399 1,405 1,400 1,392 1,392 1,390 1,388

5-11 1,898 1,932 1,949 1,973 1,998 2,018 2,029 2,033 2,034

12-16 431 422 409 399 396 396 401 409 418

Total SLC Needs school age pupils 2,329 2,354 2,358 2,372 2,394 2,414 2,430 2,442 2,452

*estimate for potential future need on reaching primary school

Over the period 2012-15 there has been a growth in the SLCN population in Worcestershire of 49% in School Action Plus in contrast with those with a statement of special educational needs which is almost stagnant, with little fluctuations, giving an overall increase of 36%.

Pupils at School Action Plus and those pupils with a statement of SEN provided information on their primary need and, if appropriate, their secondary need. Information on primary need only is given here. Includes pupils who are sole or dual main registrations.

National and regional totals and totals across Local Authorities have been rounded to the nearest 5. There may be discrepancies between totals and the sum of constituent parts.

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Figure 9: Proportion of SLCN among SEN population, 2012-15

Over 2800 children and young people with Special Educational Need at School Action Plus or with a statement of SEN are identified with SLCN as their primary educational need, which is around 4% of the total population. The number of children with SLCN as a secondary need is around 1% of the total population. Local data shows steady growth in children with persistent SLCN and an increase in the number of children entering school lacking age appropriate language and communication skills.

There is a lack of national prevalence data in the 11-19 population, which is similar to SLCN picture in Worcestershire. Using figures from the Language Link universal screen, 10% of children at the start of Reception year experience receptive language difficulties that require additional support. This proportion was similar to over 600 children, aged 5, who may be in need of additional support.

3.4.1 Local Population from Universal Screening - Early Years Foundation Stage: Language and Communication Skills

The Early Years Foundation Stage (EYFS) sets the standards for the development, learning and care of children from birth to five. The EYFS Profile summarises and describes children's attainment based on ongoing observation and assessment in the 69 early learning goals (ELGs). The profile includes 'Communication, Language and Literacy' skills in which broken into four strands: language for communication and thinking; linking letters and sounds; reading; and writing. Within each strand, there are nine skills. Children achieving six out of nine skills are considered to be developing within the expected range for their age.

In September 2012 a new EYFS Profile was introduced to assess against significantly fewer early learning goals, 17 in total. 'Communication and Language area is broken into four ELGs: listening and attention; understanding; speaking, while Literacy consists of: reading and writing. Children will be defined as having reached a Good Level Development (GLD) if they achieve 'at least the expected level' in the early learning goals.

Although EYFS profile is not a robust tool for identifying children with SCLN, it can be used to summarise the skill levels for communication, language and literacy across the 5 year old population in Worcestershire. Another advantage, it is possible to compare Worcestershire with national figures. The following table and graphs shows the % of children achieving at an expected level within Communication, Language & Literacy.

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Figure 10: Percentage of children achieving 6 or more within Communication, Language & Literacy Skills (CLL EYFS Profile) – Worcestershire compared to National percentages over the past 5 years

Communication, Language & Literacy

2010 2011 2012

%6+ National %6+ National %6+ National

Language for Communication & Thinking

84 84 88 90 88 87

Linking Sounds & Letters 80 77 82 84 85 83

Reading 76 74 79 82 80 79

Writing 66 65 69 77 71 71

Early Learning Goals

2013* 2014

At least expected

National At least expected

National

Communication & Language 71 72 76 77

Listening & Attention 81 80 83 89

Understanding 81 81 83 88

Speaking 78 78 82 87

Literacy 59 61 64 66

Reading 71 71 73 80

Writing 60 62 65 75

*New methods of communication and Language from 2013 (Early Learning Goals)

Source: Keypas

The two tables above can be summarised into the below chart:

Figure 11. Children achievement in Communication, Language & Literacy

Worcestershire children have not performed as well as the national average since the introduction of the new method for EYFS profile 2013. Performance in Communication and Language slightly better than Literacy area of learning with 1 percent less than national, and the increase in figures for both areas of learning are in keeping with the average level achieved nationally.

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Figure 12. Percentage of children achieving minimum expected level on individual Early Learning Goals of the COM (Communication and Language) and LIT (Literacy)- 2014

From 2014 figures, Redditch and Worcester City have the lowest level of ability having scored consistently below LA and national levels in across 5 individual early learning goals. The overall outcome however shows a better outlook for Communication and Language compare to Literacy, with Redditch scored the lowest of all districts, and Bromsgrove and Wychavon have the highest. The chart highlights that a large number of children are scoring poorly primarily on reading and writing and the differences are quite vast across the county.

The low proportion of children achieving the expected levels in communication, language and literacy in some districts can be explained, to a degree, by the larger proportion of children entering school, living in an environment of socio-economic disadvantage, although there may be a range of factors contributing to the outcome. In Redditch, for 2013-14 an estimated 1 in 3 children aged 5 years old (33%) lived in areas which were nationally recognised as relatively deprived (LSOAs in top 20% most deprived). This is similar to 1 in 5 (23%) in Worcester City, while Bromsgrove and Wychavon had no areas that fell into the top 20% of deprived areas nationally.

3.5 Evidence of Best Practice

St. Helens County Council produced a Paediatric Speech, Language and Communication Needs Assessment in 2014, which detailed the following evidence of best practice;

The Department for Education has published a number of good practice guides and reviews of evidence for impact. It is clear that a balance of interventions at universal, targeted and specialist levels are needed to achieve outcomes. Without the universal provision more children will be identified as needing targeted support. Without adequate targeted support, children who may have had a transient need for speech,

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language and communication support have a more persistent need, are referred on for specialist support where they may not be eligible and there may be delays in treatment. A model for provision is outlined below:

Figure 13: The Balanced System © Gascoigne 2008

A comprehensive review of evidence was commissioned as part of the Better Communication Action plan and reviewed the initiatives, approaches and treatments available. The document describes these in terms of age group (preschool, primary, secondary), who delivers the intervention, level (universal, targeted or specialist), evidence of impact and robustness of the research evidence (Law et al 2010). The section below outlines those with the most robust evidence for universal and targeted approaches. More information and resources are available through the Communication Trust www.thecommunicationtrust.org.uk

ICAN provides a training and development programme for services, settings practitioners and parents to support the speech, language communication and development of children. Each programme targets a particular age group and setting and can cover universal, targeted and specialist needs. A range of resources are available. Evaluation found good evidence of professional learning although the outcomes for children weren’t measured directly. http://www.ican.org.uk

Every Child a Talker (ECAT) was part of a national funded programme in 2008, with a lead consultant funded in each local authority who would train and support practitioners in each area. ECAT was a process and structure used by early years’ settings to improve early years’ language. It links to the early years’ foundation stage and is a universal approach that engages practitioners and parents to develop communication friendly settings. It included top tips and activities to support children’s learning. There was indicative evidence from Peterborough that children in settings where it was implemented had better outcomes than settings areas where it had not been implemented. Every Child a Talker Guidance for Early Language Lead Practitioners.

Thinking Together showed good evidence for improved language, reasoning and attainment in English and maths through using dialogue and language in learning.

Let’s Talk was a training programme for primary school staff in the Midlands who delivered language groups within the school setting. There is good evidence of the benefits to children, particularly in expressive language, although this was a small study.

http://www.thecommunicationtrust.org.uk/

http://www.ican.org.uk/

http://www.foundationyears.org.uk/2011/10/every-child-a-talker-guidance-for-early-language-lead-practitioners/

http://www.foundationyears.org.uk/2011/10/every-child-a-talker-guidance-for-early-language-lead-practitioners/

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Talk of the town (TOTT) is an evidence based community led approach that is being rolled out by the Communication Trust across 64 schools in 3 boroughs including Wigan. It is focused on improving language in primary school children to improve literacy. The pilot study in Manchester showed positive results and the full evaluation should be available in September 2015.

3.5.1 Levels of Support

From the identification of needs and impact it is clear that all children need to develop good speech, language and communication skills. The factors that affect speech and language development are widespread in the population. For that reason the approach to supporting children’s speech & language development is commonly divided into three levels:

Universal - Approaches that can be used with all children in a population or group to help good speech & language development. These are often delivered by parents, universal children’s workers (teachers, health visitors, nursery teachers) and the voluntary sector following training by speech and language therapists.

Targeted - Approaches and techniques that can be used with children who have some delay or are at risk of delay in speech and language development, often due to the risk factors above. This can be for individuals or groups and can be delivered by universal workers under the direction of speech and language therapists.

Specialist - These are needs that require specialist input to address either on a one to one or group basis which may be for a period of time.

The speech and language service currently provides training and skills to professionals involved in delivering universal and targeted support and this capacity development is part of the specialist provision.

Some local authorities have commissioned or provided speech and language therapy services as part of their SEN offer. Some of this role has been training and capacity building and part in direct work with children and families.

Schools have commissioned therapists to provide language and communication support to children individually and in groups to address language, literacy and communication needs. This has included both children with SEN and mainstream schools wishing to close the gap in attainment associated with language impairment. The Royal College of Speech and Language Therapists and Association of Speech and Language Therapists in Independent Practice produced guidance on quality standards for local authorities and schools as commissioners of speech and language therapy services in the UK (2011).

In some areas an integrated commissioning model between local authority, Clinical Commissioning Groups (CCG) and Schools has been used to meet the variety of needs. In other areas, the local authority and CCG have commissioned a core offer with schools able to purchase additional support.

3.6 Current Local Services

The Speech and Language Therapy Service was configured to meet the needs of each community in such a way that ensures each team is able to deliver an effective service across the county and settings. In delivering the service, the Worcestershire Health and Care Trust that is the provider is commissioned to pay due regard to the birth-rate, the speech and language needs assessment (October 2010), and subsequent needs assessments to support expected outcomes, including improving prevention.

Outcomes underpin the service activity, service development and service improvement. Care that is patient-centred, safe, timely, effective, efficient and equitable should also optimise service users (patient) outcomes. The service specification is attached. (Appendix. 1)

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Figure 14: Preschool Speech and Language Therapy Service

TARGETED

SPECIALIST

EVERY CHILD A TALKER 0-5 year olds

Part of the service specification with the JCU/LA

LANGUAGE LINK Identification and

Intervention

LANGUAGE FOR LEARNING TRAINING

ALLOCATED SLT TO CHILD DEVELOPMENT CENTRES AND CHILD DEVELOPMENT TEAMS

NAMED THERAPIST SERVICE IN CHILDREN’S CENTRES WITH OUTREACH TO EARLY YEARS SETTINGS – OFFERING TARGETED INTERVENTION PACKAGES

TALKING MATTERS TRAINING

WORCESTERSHIRE SLCN PATHWAY TRAINING FOR CHILDREN’S CENTRES

AND HEALTH VISITORS

ALLOCATED SLT TO SPECIALIST PROVISIONS – NURSERY LANGUAGE CLASSES, NURSERY ASSESSMENT CLASSES

SLT REPRESENTATION AT PRESCHOOL FORUM

Additional service that can be commissioned by settings, schools etc.

TALKING WALK-IN SERVICE IN CHILDREN’S CENTRES

COMPLEX NEEDS SERVICE INCLUDING DYSPHAGIA

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Figure 15: School Age Speech and Language Therapy Service

TARGETED

SPECIALIST

WHOLE SCHOOL PACKAGES

Part of the service specification with the JCU/LA

LANGUAGE LINK Identification and

Intervention

LANGUAGE FOR LEARNING TRAINING

SLT ALLOCATION TO UMBRELLA PATHWAY

NAMED THERAPIST SERVICE IN SCHOOLS – OFFERING ASSESSMENT AND TARGETED INTERVENTION PACKAGES

TALKING MATTERS TRAINING

WORCESTERSHIRE SLCN PATHWAY TRAINING

ALLOCATED SLT TO SPECIALIST PROVISIONS –LANGUAGE CLASSES, AUTISM BASES AND SPECIAL SCHOOLS

Additional service that can be commissioned by settings, schools etc.

TERMLY LIAISON MEETINGS IN ALL SCHOOLS

COMPLEX NEEDS SUPPORT IN SCHOOLS INCLUDING DYSPHAGIA

TARGETED INTERVENTION PACKAGES

COMMUNICATION TA SCHEME

REGULAR DIRECT INTERVENTION FOR CHILDREN NOT IN SPECIALIST PROVISION

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3.6.1 Language Link

Language Link is a package designed for schools to use in order to identify and support children with receptive language difficulties. The package includes an evaluation which is used to screen all children at school entry. This identifies which children require classroom based support (CBS) and which children have more complex difficulties that require discussion with Speech and Language Therapy (SLT) services.

Figure 16. Average retests for Worcestershire schools

It is currently used by 76 (First and Primary) schools in Worcestershire to identify children who require class-based support to develop receptive language and those who are in need of referral to specialist service i.e. speech and language therapy. Although the Language Link does not identify all children with SLCN, only those experiencing receptive language difficulties, it is possible to compare Worcestershire data with a national incidence figure as shown on the charts.

From average retests results across the schools, Worcestershire appears to have higher rates of pupils still requiring support than has been found nationally, in particular, pupils with EAL only. The rate for specialist services (red) appears in line with national rates however class room based support (blue) was higher in children excluding EAL. Overall, the proportion of children excluding EAL and including EAL were felt to have age appropriate receptive language skills on the Language Link screening assessment, which is in line with national levels. This compares to just 64% children with EAL only who were felt to have age appropriate receptive language skills, with approximately 29 % requiring additional support.

According to language link results, 251 children are requiring support. Combining this with the Early Years profile, it was found that at the end of the school year 2013/14 cohort of reception aged, 162 children were found not scoring 'at least expected' on Communications (COM) and Literacy (LIT), although further study would be required to ascertain if these are mostly the same children. It is thought that there are strong links between SLCN and children from disadvantaged backgrounds. Combining language link results and Early Years profiles in Worcestershire, it was suggested that 60% of children who failed to achieved in Communication and Literacy, at a receptive level, came from areas of high deprivation.

3.6.2 Talking Walk-In and Every Child a Talker (ECAT)

One of the outcomes of a Needs Assessment and Service Mapping Report completed jointly by NHS Worcestershire and Worcestershire County Council in 2010 was to commission key early intervention services for children 0-5 through the Every Child a Talker initiative and the Talking Walk-in drop in service.

One of the graphs in Figure 16 has been surpressed for data protection reasons.

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Key findings of the review of the services carried out late 2014/early 2015 are as follows (the full report is enclosed as Appendix 2;

3.6.3 Summary of evaluation of Talking Walk-Ins

Health visitors are the main referrers

Referrals at age 2-3 years have increased and this is a likely consequence of the SALT training received by health visitors, and this being implemented at the 2-2½ year check.

Parents do not necessarily attend their local children's centre. They will attend a session which fits in best with their day.

Overall satisfaction with the service is good.

Over half of parents attending are referred to a further follow up appointment. The rest are given advice and no further action is required.

During 2013-14, 497 new (unique) families dropped in.

An exercise was undertaken between September 2014 and April 2015 to analyse the postcodes of 210 families who attended a drop in. Of these 22 postcodes were unrecognised or out of county. Within the Universal settings, 0% of drop in attendees were from IMD areas 1 – 5. Within the targeted settings, 5% were from IMD areas 1-3 and 12% were from IMD areas 1-5. Within targeted plus settings, 14% were from IMD areas 1-3 and 28% were from IMD areas 1-5.

A therapist based in one place, enables them to see more children and families, without travelling time, resulting in more effective use of their time.

Children's centres are the main location to access SALT for 0-5 year olds. The drop-in element and the pre-arranged appointments are both delivered together.

Skill mix is used by having a therapist and a therapy assistant at Talking Walk-ins.

3.6.4 Talking Walk-ins - Recommendations

Make tips, activities, advice, information and guidance available on a website for parents.

Train health visitors to be able to undertake screening, which may avoid attendance at Talking Walk-ins and may offer some opportunity to reduce the number of Talking Walk-in sessions provided. The SALT service would still need capacity to train health visitors.

Ensure that refresher training for health visitors is available, due to the positive impact that SALT training appears to have produced.

Explore the number of children seen at Talking Walk-ins in conjunction with the Early Help Needs Assessment SLCN population. This would provide information around whether the numbers of children seen were in accordance with expected levels.

As a result of the analysis of postcodes of Talking Walk-in attendees, drop-ins at universal children's centres, and some targeted settings should cease. It is recommended that the alternative provision includes information, advice and guidance. The additional time available at the end of clinics within these sites can then be utilised flexibly to address pressures in the service.

Initial conclusions are that the Talking Walk-in service is well used, of good quality, provides choice for families to attend at a convenient location and time, and offers early intervention in line with best practice. The initial recommendation is that this type of service should be maintained in some form.

Any future provision needs to be considered in conjunction with the findings from the Children's Centres review.

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3.6.5 ECAT - Key findings

Of all settings which have received ECAT training, 54% are settings within IMD 1-4, 42% are in IMD areas 5 – 10 and 4% unknown

Through contacting early year's settings who have received ECAT training, 84% of those contacted within waves 1-6 reported that they still use the learning from ECAT.

Just under half of the total settings in Worcestershire (excluding child minders) are ECAT trained. However, it has taken six years to reach this point.

Feedback from those settings who are still using ECAT provided positive comments about its impact.

The 2013 service evaluation reports increased awareness of language issues across the early year's workforce, and increased confidence of practitioners to talk to parents about children's language issues.

3.6.6 ECAT - Recommendations

Initial conclusions are that a workforce programme to skill up early year's settings is successful in increasing awareness and confidence of identifying language issues within settings. ECAT is still used within 77% of settings of those trained in Waves 1 and 2 and therefore it is recommended that this programme or a similar programme is maintained.

The current pace of the ECAT programme is relatively slow as it has taken six years to cover just under 50% of settings. It is recommended that a workforce programme is designed to provide coverage to settings (targeted according to EHNA) in the most efficient way.

3.6.7 General findings

Performance of CLL score and school readiness is poor compared to the national performance and statistical neighbours, however, the CLL scoring has improved year on year since 2008. Although we cannot attribute this improvement solely to ECAT and TIWI's, these programmes will have contributed to improved outcomes.

3.6.8 SLT Service – Referrals

Figure 17: Number of new referrals to SLT service

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Figure 18: Number of new referrals to service by district by team

Figure 19: Referral Rates

It is currently not possible to show within referral data how many relate to the Neuro-Developmental Pathway. At the time of writing this Speech and Language Needs Assessment, a review of the Neuro-Developmental Pathway has commenced and the findings of this may inform the design of the future Speech and Language therapy service.

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3.6.9 Team Caseloads

Following an extensive caseload review and rigorous caseload management during 2014/15, caseloads are beginning to fall:

Figure 20: Total open referrals Figure 21: Total open referrals by team

As at mid-June 2015 open referrals by team are as follow:

Figure 22: Open referrals by team (mid-June 2015)

Total referrals as at mid-June 2015 by age are as follow:

Figure 23: Total referrals by age (mid-June 2015)

Figure 22 has been supressed for data protections reasons.

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Within the total open referrals above, some children are seen within specialist settings:

Figure 24: Children seen within specialist settings

Setting Total open referrals within these settings

Preschool Specialist Language Classes 75

Preschool Specialist Provision, i.e. Nursery Plus and Nursery Assessment Class

93

Special Schools 633

Mainstream Autism Bases 97

School Age Specialist Language Classes 63

3.6.10 Age and source of referral to SLT Services

Figure 24: Age of Referral to Speech & Language Therapy Services

Year 2010-11 % 2011-12 % 2012-13 % 2013-14 % 2014-15 %

Under 2 98 5% 105 5% 117 5% 133 5% 110 5%

2-4 years 1219 58% 1218 53% 1368 60% 1479 60% 1454 63%

5-6 years 311 15% 360 16% 315 14% 379 15% 291 13%

7-11 years 315 15% 386 17% 282 12% 288 12% 270 12%

11 years + 151 7% 226 10% 181 8% 185 8% 172 7%

Total 2094 % 2295 % 2263 % 2464 % 2297 %

Figure 24: Source and age referral to SLT Services 2010-15

Referral Sources Infant (0-2)

Pre-school (3-5)

Primary (6-11)

Secondary (12-16)

17-19

TOTAL

Allied Health Professional 90 83 145 88 12 418

Carer/Self-Referral 345 779 94 13 <5 1231

Community Health Services 137 41 10 305

Community Nursing 61 117 26 <5 <5 208

Consultant 233 144 126 42 <5 549

Educational Establishment 72 1910 1482 260 8 3732

General Medical Practitioner 46 147 121 43 <5 361

Health Visitor 1512 2183 <5 <5 <5 3700

Speech Therapists (e.g. transfers)

88 109 44 21 <5 263

Local Authority <5 <5 <5 <5 <5 29

Other 116 187 189 102 21 615

Total 2620 5727 2387 616 61 11411

Some of the data in Figure 25 has been supressed for data protection reasons.

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The largest proportion (two thirds) of sources of referrals between 2010-15, came from Educational Establishments (33%) and Health Visitors (32%). Carer or Self-Referral is considerably significant with over 11% referrals. As shown, three quarters of children referred to the Speech and Language Therapist services for the last 5 years were on pre-school stage (0-5 years old). At the start of 2011-12 there was an increase of health visitor referrals for 2 years old and has since seen a steady rise year on year. Referrals for 3 year olds still stays the highest on every observation year, averaging 47% of the total yearly referral made by Health Visitors.

As expected, the educational establishment data shows that children from nursery/reception stage (3-5) and those over 5 years are being referred. Both age groups are more or less on similar proportion, with referrals for 3-5 year olds on the increase. This makes up approximately one fifth of an average annual referral from an educational establishment.

This concludes that Educational Establishments have played a very important role and have fully understood the importance of identifying SLCN issues and establishing swift referrals from very early on, particularly for those children in pre-school and reception class.

Figure 25: Proportion of sources of referral, 2010-15

Figure 26: Proportion of age at referral, 2010

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3.6.11 Health Visitor referral

The table and graph below shows health visitor referrals for Worcestershire children between 2010 to 2015. Health visitors are the main referrers to this service; the number of referrals has increased year on year, particularly at age 2 and 3, which suggests that the 2½ year check is the time when referrals are made (please refer to the Health Visitor's chart on the next page). As shown, the number of health visitor referrals for 0-1 year olds and 5 year olds are quite steady and low but there is an opposite trend for 2-3 year olds where there has been an increase in referrals since 2011. In the last year, the increase in referrals for both groups were on the same rate, with the 3 year olds group having the highest number of all. Health visitors have received training from the speech and language service and an evaluation of training delivered to health visitors shows an increase in health visitors understanding of the typical stages of speech, language and communication development and therefore increased confidence in identifying SLCN issues.

The pre-school projects may have led to a significant increase in appropriate referrals for children in this group. It shows that health visitors are referring more children at the age of 2 which indicates that SLCN issues are being identified earlier, most likely at the 2-2½ year check. The charts also outline that most referrals to the speech and language service are made before children reach the age of 4 years. This suggests that early intervention is being implemented.

Figure 27: Health Visitor Referral to Speech & Language Therapy Services

Year 2010-11 %

2011-12 %

2012-13 %

2013-14 %

2014-15 %

Under 1 year <5 <1% 8 1% 6 1% 10 1% <5 1%

1 year olds 33 <1% 41 6% 43 6% 54 7% 44 6%

2 year olds 208 29% 208 34% 240 34% 280 35% 327 41%

3 year olds 348 48% 317 47% 328 47% 371 46% 343 43%

4 year olds 106 15% 86 10% 72 10% 77 10% 66 8%

5 year olds 17 2% 11 2% 15 2% 13 2% 13 2%

Over 5 year olds <5 <1%

<5 <1% <5 <1% <5 <1% <5 <1%

Total 721 % 671 % 704 % 805 % 798 %

Figure 28: Health Visitor Referral to Speech & Language Therapy Services

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Total number of Health Visitor referrals has reduced - slowing down of referrals can be seen across

all locality teams.

Across the county the % of children referred at age 4 or below has increased stable at 68%.

There is an ongoing increase in referrals made by health visitors before the age of 3, with a 7% increase during the last year.

The numbers of self-referrals/referrals made by parents within the under 5 age range continues to be high. This is reflected in the steady number of drop ins at Talking Walk-Ins across the county.

The charts outline that most referrals to the speech and language service are made before children reach the age of 4 years. This suggests that early intervention is being implemented as far as possible.

3.6.12 Educational Establishment Referrals

The graph below shows the numbers of referrals by age from educational establishments to the speech and language service. There has been a gradual but steady increase in the numbers of under 5's referred to the service, suggesting that earlier intervention is being implemented and recognised by educational establishments.

Figure 29: Educational establishment referral

The table and graph below show that there has been a higher number of referrals for SLCN, than any other condition, when a child is referred by a Pre-School. It could be suggested that this is due to increased training, such as Every Child a Talker (ECAT), within Pre-Schools, to identify SLCN needs earlier.

Figure 30: Referrals to Pre-School Forum by Need

Year ASC SLCN Cognition and Learning BESD

Sensory, Physical or Medical

2009/10 51 218 122 39 63

2010/11 49 275 104 50 59

2011/12 52 286 90 39 85

2012/13 80 299 101 39 97

2013/14 39 150 45 6 80

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Figure 31: Referrals to Pre-School Forum by Need

*2014/15 data not available until late July/early August 2015, once the academic year has ended.

3.6.13 Caseload and Population

Caseloads are now in line with predicted incidence of SLCN:

Figure 32: Caseloads by district

District Caseload (open referrals)

% of county caseload

Predicted % of SLCN

Under 19 population

% of under 19 population

% of under 19 population on SLT caseload

North West Wyre Forest

1318 21% 21% 20,186 17% 6.5%

North East Bromsgrove & Redditch

1890 30% 30% 40,053 33% 4.7%

South Worcestershire Malvern Hills, Worcester City and Wychavon

2990 48% 48% 61,540 51% 4.8%

Totals 6198 % % 121,779 % %

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3.7 SLT waiting times

The target maximum waiting time is 18 weeks from referral to first intervention. From March 2012 until March 2015, the new referrals waiting longer than 18 weeks had been quite steady, with a low of 0.6%. However, from Feburary 2015 there was an increase of up to 10% of new referrals waiting longer than 18 weeks. The next group of 16-18 weeks waiting time shows a rather fluctuated movement and has started to rise from February 2015.

In March - April 2014 there was an increase of 8% in waiting times and by the end of August 2014 this had decreased to 4% but was unstable and was soon back to the upward trend from February 2015. In April 2015 the service breached the 95% target for patients waiting over 18 weeks to first appointment. The waiting times are in relation to early years appointments in one team. There are no breaches for SLT elsewhere in the county.

As of 11/05/2015, 53 children were reported as waiting over 18 weeks for their first appointment. The breakdown is as follows:

Offered appointment and refused – 1; Appointment booked – 37; Yet to be offered – 12; NCRS errors – 3.

The waiting times are linked to an unprecedented number of vacancies with over 7 wte leaving the team within a period of 3 months and the subsequent delay in recruiting. At this time only 50% of required staff were available for the Talking walk-ins in the south of the county. This trend is being monitored closely.

Figure 33: Paediatric S&LT Waiting Time, Mar 2012 – Jan 2015

3.8 Reasons for discharge

Referrals discharged without the young person being seen due to various reasons between 2011-14 stand at an average of 25%. A large proportion of the reasoning behind the discharges were because there was no contact or no request for further involvement, this was closely followed by the 'child moved'. 'Other reasons' which make up the least of overall reasons for discharge, include failed to attend, inappropriate

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referral/treatment not necessary, self-discharge or refusing treatment, left school unable to contact family and in the rarest case, the child died.

Figure 34: Reasons for discharge, 2011-14

Looking at the proportion of children by their school age, a high proportion of reception age children have been discharged due to reason of no contact/no request for further involvement and the trend is quite steady for the past 3 years. The same age group also has quite a visible proportion of children that have been discharged due to 'failed to attend appointment/treatment'.

Figure 35: Reasons for discharge by age group, 2011-14

3.9 SEN Data

SEN data for school age children is collated centrally once a year, each January, as part of the School Census. Information on children at School Action and School Action Plus is taken directly as submitted by individual schools. The School Census requires that in the case of a child with SEN, the primary need must be specified (a secondary need may also be specified). There is a category of Communication and Interaction Needs that specifies two subgroups, namely Speech, Language and Communication Needs and

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Autistic Spectrum Disorder. There are few changes in some areas as a result of new SEN Code of Practice that came into effect from September 2014. The changes include:

- the separate school action and school action plus categories are being phased out to be replaced by a single category ‘SEN support’

- SEN statements will be replaced with education, health and care plans’ (E Plans) - new code ‘SEMH’ for ‘social, emotional and mental health’ as a direct replacement for ‘BESD’ - new code ‘NSA’ for ‘SEN support but no specialist assessment of type of need’. For pupils

previously recorded at School Action, a SEN type ‘NSA’ can be recorded in the Census if a specific need has not been identified. (SEN type has not previously been collected for pupils at School Action).

The data provided in this section of the report is based on children with SLCN listed as their primary educational need only.

Figure 36: Number of children with SLCN identified as primary educational need

Need 2012-13 2013-14 2014-15

Total SLCN % Total SLCN % Total SLCN %

Children at School Action Plus 7412 1880 25 7579 2118 28 9953 2465* 25

Children with a SEN Statement

2331 430 18 2303 437 19 2253 396 18

*includes all under SEN Support (SA & SA+)

Figure 37: Proportion of SLCN as primary need by district

District 2012-13 2013-14 2014-15

Bromsgrove 13% 13% 15%

Malvern Hills 9% 8% 9%

Redditch 16% 17% 18%

Worcester City 18% 21% 20%

Wychavon 19% 18% 17%

Wyre Forest 22% 22% 20%

Overall 25% of children on School Action Plus and 19% on SEN statement have the primary need of SCLN, with Wyre Forest persistently having the highest proportion of these children as oppose to Malvern Hills which has the lowest proportion across the county.

At School Action Plus, Worcestershire children with SLCN as a primary educational need are constantly the largest group as shown on the figure below. The proportion of children with SLCN as a primary need with a statement is second largest after ASD. All children and young people with ASD will experience SCLN. The number of children with secondary SCLN in association with mild learning difficulties and BESD/SEMH for the past 3 years, can be identified on average 33% and 22% respectively and when combined, represents more than half of this population.

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Figure 38: Average proportion of Worcestershire children with SEN Primary Need for 2012-15

Notes:

SPLD – Specific Learning Difficulty

MLD – Moderate Learning Difficulty

SLD – Severe Learning Difficulty

PMLD – Profound & Multiple Learning Difficulty

BESD/SEMH – Behavioural Emotional & Social Difficulties/ Social, emotional and mental health

SLCN – Speech, Language & Communication Needs

HI – Hearing Impairment

VI – Visual Impairment

MSI – Multi-Sensory Impairment

PD – Physical Disability

ASD – Autistic spectrum disorder

OTH – Other difficulty/disability

NSA – SEN support but not specialist assessment of type of need

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Figure 39: Educational placement for children with SLCN listed as their primary need

School Year

2012-13 2013-14 2014-15

School Action Plus

Statemented

School Action Plus

Statemented

SEN support (SA & SA+)

EHC Plans (Statemented)

Total % Total % Total

% Total

% Total % Total %

KS1 810 53%

151 10%

915 55% 136 8% 989 55%

810 53%

KS2 452 29%

126 8% 476 29% 143 9% 532 30%

452 29%

Primary School*

1547 82%

209 49%

1779

84% 204 47%

1995 81%

169 43%

Middle School 100 5% 30 7% 99 5% 27 6% <5 % 29 7% Secondary School

222 12%

125 29%

224 11% 108 25%

311 13%

90 23%

Special School 10 1% 66 15%

8 0% 98 22%

<5 % 107 27%

Grand Total 1879 % 430 % 2118

% 437 % 2465 % 396 %

*including Middle Deemed Primary

Some of the data in Figure 40 has been supressed for data protection reasons.

Looking at the distribution of children with SLCN as a primary need, at School Action Plus across the educational placement the proportion is significantly decreased. However, it also highlights that language and communication needs persist beyond the primary stage into secondary.

Examination of prevalence by age group, using the School Census, revealed that for many pupils having SLCN, identified in the early years of primary school, is temporary, with identification at the level of School Action Plus (SLCN Plus) decreasing substantially from 11% in Year 1 to 2% in Year 7 and further reducing to Year 11. However, this occurred mainly during Key Stages 1 and 2, with a much lower rate of decrease during Key Stages 3 and 4. Furthermore, this reduction was essentially a function of fewer pupils at SLCN Plus: the prevalence of pupils with statements where SLCN was the primary need was relatively stable at around 1% across the full age range (5-16 years). In conclusion, there is a substantial reduction in the proportion of pupils with SLCN at School Action Plus over Key Stages 1 and 2, suggesting that for many pupils SLCN identified in the early years of primary school are temporary and transient.

Figure 40: SLCN prevalence across year groups 2015

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The number of children with SLCN as primary need within each SEN category can be seen on the below charts. Based on gender, Boys are persistently outnumbering Girls in almost all categories, ASD is the most disproportionate category with a ratio of 1 girl to every 5 boys, followed by BESD and SLCN.

Figure 41: Number of children by Primary Educational Need 2012-13

Figure 42 has been supressed for data protection reasons.





3.9.1 Pre-school children

The exact number of children with SLCN with a special educational need at pre-school level is difficult to quantify as data is sourced from the school census, excluding those children at Early Years settings, despite the Early Years data available, albeit limited to top indicator. For instance, the number of children at Early Years settings (including private, voluntary and independent) with special educational need is counted and categorised based on Action Plus, with Statement and so on but does not specify to the sub needs of primary/secondary, therefore the number for SLCN is unknown. However, the proportion of children from early years settings identified with special educational needs has been constantly very low (below 5%) therefore a conclusion can be built based on census data.

Figure 44: SLCN prevalent rate in preschool SEN population

District 2012/13 2013/14 2014/15

Bromsgrove 10% 10% 12%

Malvern Hills 6% 5% 7%

Redditch 9% 9% 10%

Worcester City 10% 15% 11%

Wychavon 13% 11% 8%

Wyre Forest 11% 14% 16%

SLCN preschool prevalent rate 61% 65% 64%

SLCN has a high proportion as a primary need among other SENs in all areas of the county. Wyre Forest has the highest number of SLCN prevalence whilst Malvern Hills is the lowest compared to the rest. Despite some districts showing a healthy decline in SLCN incidence, this is not the case for Worcestershire overall, which shows increasing trends that makes SLCN is the most prevalent type of SEN at a preschool level in Worcestershire.

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3.10 IMPACT ON EDUCATIONAL ACHIEVEMENT

3.10.1 General Impact Data

Although there is a great deal of variation in adolescence, there is clear documented evidence that children and young people with SLCN have been shown to be at a greater risk of lower academic achievement and school performance failure. At the root of the relationship between SLCN and poor academic attainment is the link between early spoken language skills and subsequent reading and writing skills. The impact of SLCN on educational attainment is strongest in the areas of literacy and numeracy. The ICAN report 2006 takes this further by describing the cost to the nation of children's language and communication needs.

The table below shows that Worcestershire's performance is below national figures for school readiness and also below many of our statistical neighbours.

Figure 45: School Readiness, 2012-13

Area School Readiness 2012-13

Area % of children achieving a good level of development at the end of reception

% of children with free school meal status achieving a good level of development at the end of reception

England 51.7 36.2

West Midlands 50.0 36.1

Worcestershire 49.4 26.6

Stat Neighbours: % of children achieving a good level of development at the end of reception

% of children with free school meal status achieving a good level of development at the end of reception

Dorset 60.9 40.0

East Sussex 43.6 26.7

Essex 52.5 34.7

Hampshire 58.9 37.4

Leicestershire 46.3 24.7

North Somerset Not available: (Somerset 53.3) Not available: (Somerset 31.1)

South Gloucestershire 67.0 47.1

Staffordshire 53.6 36.1

Warwickshire 44.9 26.2

West Sussex 52.4 33.2

Source: Public Health Outcomes Framework

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Figure 46: 2014 EYFSP - Communication and Language - % of children achieving at least expecting

2014 CLL 2013 CLL (High is good)

2014 CLL (High is bad)

Area % achieving at least expected

% achieving at least expected

% Improvement year on year

% achieving at least expected in 30% most deprived areas

% Diff to all children

National 77 72 5

70 7

West Midlands 75 70 5

69 6

Worcestershire 76 71 5

63 13

Stat Neighbours:

Dorset 84 81 3

74 10

East Sussex 83 70 13

77 6

Essex 78 73 5

72 6

Hampshire 84 78 6

73 11

Leicestershire 78 71 7

67 11

North Somerset 86 84 2

75 11

South Gloucestershire 83 82 1

87 -4

Staffordshire 80 74 6

71 9

Warwickshire 76 66 10

68 8

West Sussex 80 76 4

73 7

The EYFSP results around CLL indicate that Worcestershire is not performing as well as its statistical neighbours and there is a significant gap in performance to the children in the most 30% deprived areas.

* Statistical neighbours updated October 2014

The above table shows that Worcestershire CLL scores have improved year on year since 2008, but this improvement cannot be attributed solely to Talking Walk-ins or ECAT. The work of the school improvement teams would also contribute to this improvement.

The Early Help Needs Assessment looked at examples of evidence-based good practice of early intervention speech and language.

The chart below shows a summary of key attainment data at Key Stage 2, to ascertain the educational outcomes of children with SLCN compared to all pupils, in both Worcestershire and nationally. The chart shows relative academic attainment of children with SLCN compared to all children at age 11 (Key Stage 2). Due to unavailability of National data specific for SLCN children, instead we use data of children with SEN Action/Action Plus where SLCN need identified as the largest group of the cohort.

EYFSP - % 6+ CLL 2008 2009 2010 2011 2012 2013 2014

Worcestershire 45 51 60 65 67 71 76

National 52 55 59 62 66 72 77

Stat Neighbours* 61 61 62 62 69 76 81

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Figure 47: Percentage of pupils achieving Level 4+ KS2 2014

Worcestershire children with the primary need of SLCN performed poorly compared to their peers and their results do not seem to have too much discrepancy with those with ASD. Nationally, 42% pupils with either at School Action or at School Action Plus reached the expected level for their age in Reading, Writing and Maths at age 11 compared to 79% of all pupils – a gap of 37%. For Worcestershire children with SLCN, they considerably have much larger gap of 51% compared to their peers, although these same children performed much better at Reading and Maths which is a positive sign that children with poor language skills are still able to access some of the wider curriculum. However, these gaps overall are significant.

Looking at the last 5 years of data between Worcestershire SLCN cohort and their peers (locally and nationally) the gap is quite stable, which suggests there has not been much improvement in their academic performance. Even when compared with pupils at Action or Action Plus nationally, with the exception of 2012 where the gap reduced, the gap is quite stable. However, this could be explained by the introduction of the new performance indicator of combined Reading, Writing and Maths (RWM), in place of combined English & Maths (EM), which gave smaller figures compared to the previous year as the standard assessment in writing was yet to be implemented nationally. Interpreting this result in another way, 3 in 4 children with SLCN in Worcestershire failed to attain the standard level 4+ in reading, writing and maths.

Figure 48: Percentage of pupils achieving L4+ in Reading, Writing & Maths

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4. Outcomes Assessment

4.1 The Early Help Needs Assessment Report

The Early Help Needs Assessment Report (January 2015) presents the following information:

Effective SALT interventions include:

the use of individual and group work are equally effective (group work should have better cost effectiveness).

The use of trained parents is just as effective as clinicians in administering therapy.

Interventions are most effective if they last at least 8 weeks.

Effective interventions particularly targeted at improving emotional wellbeing and resilience:

Peer mentoring.

Social skills training (SST) e.g. problem solving skills.

4.2 Evidence of successful Speech and Language interventions and models of care.

Primary speech and language delay/disorder is a common developmental difficulty which can endure into adolescence and beyond if unresolved (Law, Garrett & Nye, 2005). It can present as a secondary difficulty, resulting from a primary cause such as autism, sensory impairment, or neurological problem; or it can be a primary difficulty with an unknown cause. Difficulties of both language and socialisation can result and the implications can be far reaching for the child, parent and carer, including adverse effects on school achievement. It is thought that, on average, around 6% of children have speech and language difficulties (although estimates can vary from 1% to as high as 15%) of which a significant proportion will have primary speech and language difficulties.

Presentation of primary speech and language delay/disorders can vary considerably (Ibid.): difficulties can be transient or persistent and present as delayed or disordered speech, along with receptive language difficulties (understanding others) or expressive language difficulties (sharing thoughts and feelings), or a combination. There is little consensus on the aetiology of language delay/disorder, but it may be correlated with chronic otitis media, genetic factors, socioeconomic status, difficulties in pregnancy and oral-motor difficulties. It may be these act in a cumulative fashion to increase the severity.

In addition to the impact on educational outcomes, speech and language delay/disorders can be associated with social, emotional, behavioural problems (Ibid.) These can endure into young adulthood and beyond; 30-60% of children experience continuing problems with reading and spelling therefore speech and language delay/disorder has the potential to impact significantly on the individual, family and society in both the short and long term.

Interventions:

Evidence suggests that speech and language therapy for children with expressive difficulties can be effective.

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However, evidence is limited as regards the effectiveness of interventions for children with receptive language difficulties. This is a concern as research shows that these children are least likely to resolve and more likely to have long term sequelae (co-morbid conditions).

Studies of the effectiveness of interventions rarely include a measure of long term follow-up therefore it is hard to determine how the effect of SALT had worn off at 6 months post-intervention.

There is no statistically significant difference between the effectiveness of using trained parents and clinicians in administering interventions, so either can be used successfully.

There also appears to be little difference when comparing group and individual interventions – both appear to be just as effective.

Studies have found that interventions lasting longer than eight weeks are more effective.

Evidence also supports the use of normal language peers in interventions as language models for children with language impairment.

4.3 Outcome / symptom specific evidence

Effective speech and language skills are key to the happy and healthy development of children, particularly in terms of educational achievement. Just as important though is the ability of the child to socialise and make friends; this requires confident communication skills which should not be underestimated.

Many research studies also emphasise the value of working together. Wright (1996), for example, states that, ideally, teachers and therapists, who are supporting a child with language needs, should work together with the child’s parents to provide a co-ordinated plan of intervention.

Collaboration between SLTs and teachers is also driven by the SLTs change in practice. Law et al (2002) describe how, traditionally, when SLTs were clinic-based, they worked with individual children and focused on ameliorating or repairing the impairment experienced by the child. Law et al continue that the approach of SLTs now is more holistic and there is an emphasis on support for the child being given, via others, within the classroom environment (Lisa Thirston, 2008).

5. Policy and Financial Context

5.1 Statutory duties

The current Speech and Language Therapy Service specification was developed in the light of:

Bercow Report – A review of services for children and young people (0-19) with Speech, Language and Communication Needs, 2008.

Better Communication Plan (2008)

Royal College of Speech and Language Therapy position paper 'Supporting Children with Speech, Language and Communication Needs within Integrated Children's Services' (Gascoigne 2006)

Every Child Matters Agenda

Integrated Working and the Common Assessment Framework (CAF)

Safeguarding Children (Worcestershire Safeguarding Children Board)

Worcestershire Children and Young People's Plan 2011 – 2014

Communicating Quality 3 (Royal College of Speech and Language Therapy, 2006)

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Recommendations from the Royal College of Speech and Language Therapists (RCSLT), which sets professional standards, (Royal College of Speech and Language Therapists, 1996) also emphasise the need for joint working in order to develop good practice.

In the recommendations for service delivery by SLTs to mainstream schools, the first aim is about sharing knowledge, skills and expertise. The second directs SLTs to ensure that speech and language therapy input is part of a total programme for the child. More recently, The College’s Position Paper (Gascoigne, 2006) aims to set out the recommendations from the RCSLT on the role of SLTs within the development of children’s services. This is a response to the guidance, which is part of the Children Act 2004, that professionals should work in a ‘team around the child’ and the proposals represent a significant development from earlier advice from the RCSLT. Included in the recommendations are that:

SLTs should identify speech and language needs as part of a multidisciplinary team;

support should be provided in the setting which is most appropriate for the child and their family and

the RCSLT regards trans-disciplinary working as central to working with children.

5.2 Budget

The SALT service is funded as follows;

Figure 49: Funding for SLCN

Elements of the Service Budget Amount

Talk-in-Walk-in; Every Child a Talker (ECAT); Speech and Language Therapist (SALT) Service

*

*Some of the data in Figure 50 and 51 has been supressed as this data is commercially sensitive.

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6. Assessment of Current Services

Figure 50: Action plan from SLCN service redesign, 2010

Action Plan from 2010 Service Redesign

What Happened Gaps, Further Action and Recommendations

SCLN Pathway

A rolling programme of training to support practitioners in making best use of the available resources.

The SLCN Pathway was launched in 2011. Awareness level training rolled out and further training available for school staff to purchase

Ongoing update and promotion of the Pathway moved to the provider organisation's website.

Universal Provision

Appropriate information and advice to parents and carers via the Pathway and ensure that all professionals, parents and settings have access to appropriate information and advice to support the development of speech, language and communication skills.

Achieved through the above training, launch of the SLCN Pathway and ongoing promotion of advice and support through SLT social media – Facebook and Twitter.

Information and advice to be agreed and updated on a regular basis. Ensuring hard to reach families access advice and information will require ongoing consideration and flexibility of approach, including training of SENDIASS and frontline customer services e.g. Access Centre

Ensuring communication and language friendly environments (CFEs) in settings

ECAT, Children’s Centre SLT support, Talking Walk-In service and targeted interventions funding merged with NHS funding to deliver the new early years Children’s Centre service, bringing universal and targeted services together. ECaT delivered successfully, reported within the workforce report each year.

The report on impact of Talking Walk-in separately conducted annexed to this Needs Assessment (Appendix 2)

Training of the early years workforce

A range of training opportunities of varying cost and quality is available. ECaT - as above. Children’s Centre SLCN Pathway training - as above. Training opportunities are also available through Language for Learning. The Early Years' Service reintroduced other SLCN training delivered by Area SENCOs separate from, and not co-delivered with, the SLT service

Menu of additional training opportunities to be agreed and rationalise funding and delivery model for efficiency.

Early identification - using the health visitor 2 ½. year check that ensures children with identified SLCN to be referred to targeted level service.

Part of current HV contract Ensure ongoing SLCN Pathway training for HV because of the increase in the number of 2 year olds referred to the SLT service.

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Language Link for 4-5 year olds

Language Link was rolled out and continues to be funded by schools with new schools joining the programme each year. The funding for the on-going operational management of Language Link ceased in April 2014 when the additional funding for ECaT (this included funding for Language Link) came to an end.

Local funding for the ongoing operational management required to roll out to all remaining primary schools. Monitoring of the wider workforce development needs to be built into performance outcome measures.

Additional services for schools and settings to purchase locally at ALL levels.

A booklet detailing the core offer and additional services available including quality specifications and guide prices published in 2014, accessible and in use.

Managing delivery of the core funded services and additional services, i.e. organising a more flexible delivery and staffing to ensure expected outcomes are achieved will need careful consideration and planning.

Targeted Provision

Competent and confident practitioners able to deliver small group targeted intervention

Within current SLT contract, Specialist teacher funding that is now a full cost recovery service, separately commissioned to the SALT service.

Integration of speech and language therapy and specialist teacher services (LST) to remove any duplication and more efficiency to be considered.

Talking Walk-ins in all Children’s Centres

Children’s Centre SLT support. Targeted assessment within current SLT contract. Regular drop in sessions run at Children’s Centres as part of the Talking Walk-In service.

Integration of universal and targeted support in Children’s Centres with link speech and language therapists carrying out both activities to be strengthened and the universal provision considered as part of Early Help provision.

Termly liaison with all schools by link speech and language therapists and/or specialist teachers

No integration with specialist teacher service. Both services currently attend and represent their ‘own’ service.

As above.

Rolling programme of targeted interventions in Children’s Centres and schools

Within current SLT contract - Specialist teacher funding

As above

Specialist

Multi-agency assessment to identify persistent and complex SLCN

The SLI Pathfinder Project had a successful launch with training for all professionals involved. SEND reforms require joint assessment for EHC plans. CASBAT – all of the CAMHS/CASBAT time allocated within the service is now committed to the Umbrella Pathway.

The pathway has been become problematic in the past year with the changing role and provision of EPs. The SLI pathway needs to be reviewed in the light of this changing role and a national debate regarding the assessment of SLI together with the use of the term SLI.

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Specialist support for practitioners in settings and schools to facilitate effective implementation of specialist interventions and direct support from SLTs as appropriate

Within current SLT contract with LA - Specialist teacher funding. There has been no integration of time with the specialist teacher service – see above. Pre-School Age language class's provision has been reviewed and commissioned for one year from September 2015.

Integration of speech and language therapists within specialist teacher services (ISSS) to be considered. Role of specialist workforce within specialist provision, i.e. language classes can also be explored. It is observed that if the current allocation is shared between all the proposed 6 LU's – then the input from SaLT would be halved and this will reduce the provision from being an enhanced service. Pre School and Schools do not have capacity within the current allocation to meet all their needs. Level of need within the new EHC assessment process need to be factored into the Therapists input.

Local agreement for specialist assessment and intervention

Within current SLT contract - Specialist teacher funding. No action taken yet.

Requires strategic and operational discussion and agreement.

Training

Centralised training and workforce development

Workforce plan is published and linked to the SLCN Pathway.

Exercise to rationalise and agree training is needed as well as potential cost for coordination of training.

Leadership

Strategic and operational leadership

Management structure now aligned with the service specification with county wide leadership for each aspect of the service.

Current structure to be reviewed in line with any new service model

6.1 SCLN Service and Youth Offending

Following the redesign in 2011, one session per week provision was identified within the service's CAMHS/Umbrella allocation but this stopped when the new Umbrella Pathway was rolled out. Services provided then include: screening assessment, advice on case by case basis, face to face contact with young people and collaborative training work.

From Nov 2010 to Nov 2011, 367 children were seen by the Youth Offending Team (YOT), 503 offences in total (i.e. including re-offending). Below are the numbers of young offenders in Worcestershire over the

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last four years. These are all the young people who have had a police reprimand, warning or caution or who have been convicted in court during the year. Since January 2014, there has only been 7 referrals from the YOT about young people with possible speech and language difficulties. The introduction of the CHAT assessment toolkit within YOS will support earlier identification of speech and language needs.

Figure 51: Numbers of Young Offenders in Worcestershire over the last 4 years.

Year Number of offenders

2011/12 587

2012/13 520

2013/14 422

2014/15 374

A Short Quality Screening (SQS) inspection of youth offending work in West Mercia by HM Probation Service has just been conducted. One of the areas requiring improvement is that assessments and interventions of the speech, language and communication skills worker should be available across all areas of the YOS.

Good quality assessment and planning at the start of a sentence is described to be critical to increasing the likelihood of positive outcomes.

7. Aspirations of the Population

7.1 Feedback from Early Years settings

A survey was conducted across early year's settings to gain their feedback on the speech and language support provision and below shows the summary:

Figure 52: Feedback from Early Years settings

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7.1.1 How are the Speech and Language needs of the children in your setting met?

Training – Many groups noted the benefits of training such as ECAT, this enabled staff to confidently cater to children's speech and language needs within the early years setting, which meant that issues were being addressed without the need for a referral to a specialist.

Joint Working – Liaising with and working closely with speech and language therapists meant that workers were able to get advice, understanding and gather resources from therapists and were also able to follow IEPs and set and follow targets. SENCOs were also largely involved in this process. However, one nursery explained that 'Input from NHS SALT is inadequate to meet our needs' and therefore they had a SALT team employed directly by the school and upskilled their workforce through increased training.

Communication - Communication with parents was also key to meeting the needs of children, ensuring that parents were made aware of work that was being completed in the early year's settings and also encouraging parents to continue this work at home. Also the need to be involved and informed about the child's individual needs from a staff members point of view was key, whether this was via a speech and language therapist or the parents passing on the information from the therapist.

Targeted approach – Groups mentioned the use of small groups and 1:1 sessions as part of a targeted approach. This gave workers the opportunity to focus on individual child's needs and individual targets in order to adopt an approach best suited to the individual.

7.1.2 What training has your setting attended in matter of Speech and Language? (e.g. ECAT, Language for Learning)

ECAT was completed by most PVI groups and maintained nurseries but <5 childminders had received the training. Other courses that were attended included Language Link, Language for Learning and Sign along. <5 out of 45 PVI groups had completed no training. 10 out of 29 childminders had completed no training. All of the maintained nurseries had completed a training course.

7.1.3 Have you any suggestions for improvement to the service provided?

Waiting Times – There was an emphasis on the need to improve waiting times when initial referrals are made to the service.

Training – There was a need for increased training opportunities at more accessible times, such as evenings.

SLT Visits – Visits by speech and language therapists need to be more frequent, there needs to be more follow up appointments in the setting where the child spends a great deal of time. In some cases groups stated that a SLT had never been to their setting.

7.2 Feedback from Special Schools

7.2.1 General Comments on the SALT Service

Overall the schools felt that individual therapists often do a good job within the school but that their effectiveness is reduced because of the following reasons:

7.2.2 Allocation of staff

1. There are no clear criteria of how the staffing levels in each Special School are decided (BESD schools often negatively affected)

2. Level of staffing does not alter to support changing need in the school population

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3. Staffing levels prone to change e.g. staff are not replaced when they take maternity leave, leave

their posts or are off on long term sickness

4. Parents are not kept informed of changes in staffing levels or personnel.

7.2.3 Roles within the school

1. Focus on language rather than speech

2. No identifiable impact measures which are shared with school

3. Role consists of reviewing pupils, creating targets and writing reports. Not enough time for direct therapy with children

4. Limited flexibility in working in different ways to meet the needs of different schools (e.g. overlap if a school has employed their own therapist)

5. Lack of communication with parents about how much direct intervention their child actually receives.

6. Statements of Special Education Need usually contain only broad outline, lack of clarity.

7. Children are discharged without consulting the school

8. Significant time spent on admin duties, schools no longer able to support this (e.g. filing)

7.2.4 Present Service Delivery Arrangements

1. Lack of clarity leads to schools being unsure about the therapists' remit e.g. clinical supervision, training – schools are told neither of these is commissioned but has no documentation to check this

2. No clear information regarding the scope or original commissioning because written information (commissioning document) is not readily available in schools

3. Procedures if school are not satisfied with the Service are unclear

4. The service user (Special Schools) play no part in on-going Performance Management.

7.3 Focus Groups with Parent Carers

As part of this Needs Assessment process Children's Services Parent Engagement Advisor (PEA) undertook a series of focus groups with parent carers to get their views on the services on offer. This was to add some contextual intelligence to the data collected via the online questionnaire. Below is the summary of the group sessions (full report in Appendix 3):

For the purposes of the engagement the responses have been collated under the three questions that the respondents were asked. Individual responses were then grouped under themes and commentary made to outline these – where appropriate actual quotations have been used to illustrate the points.

7.3.1 What went well?

In general the service was really valued when the parents felt included and involved. When a parent had been involved in the sessions, and interventions were explained to them, they said they felt supported and respected.

'I had regular contact with my SALT and she was able to observe me with my children, and give tips about the best way to communicate with them. I was given exercises to do with them at home and the rationale behind it was explained, it was great. I felt I was involved and adding real value to the therapy, increasing the chances of success.'

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Progress updates and conversations about future support and interventions, along with discussions about appropriate settings/schools were also considered to be important and useful.

'I've had excellent support from my therapist in the past – with update phone calls and regular text messages. I felt included and knew what support my child was getting in school.'

Parents really liked being given exercises to do with their children at home; they felt this supported the work that the therapists were doing in the sessions. All the parents remarked that it was important that the exercises were explained to them and not just sent home without instruction.

'By sitting in, I was able to see what was happening and then replicate it at home. I was given worksheets and activities, which I could carry on at home.'

The 'walk in' sessions at Children's centres were very popular, parents liked that they could access the service themselves without having to go through another professional. They liked that the service was available locally, and they didn't have to travel a long way to get to it.

'The service was a god send; I don't know what we'd have done without it. It's a really good idea'

'it was great that I didn't have to go through the Drs and involve lots of other professionals, I liked that I could just walk in and see someone face to face immediately.'

7.3.2 What not so well?

Communication – by far the biggest complaint that parents had was not being told what was going on. Parents who didn't feel involved and included felt that their children hadn't received such a good service. A number of parents remarked that they didn't know who their child's therapist was, or the number of times that they see them.

A common complaint was being sent home paperwork without any explanation – as more than one parent said 'you get a random report every now and then'.

'I have no idea who my child's therapist is, or how many times they are seen in school. I get targets twice a year, in a brown envelope, with no explanation – I don't feel involved or included, or have any idea how I can help at home'. 'I had to ring the (special) school to find out what therapy my child was receiving and how often'

Changes to personnel – parents appreciate that people move jobs, but in some cases children had had a number of different therapists and there was little or no relationship building or continuity.

The referral process can often be slow and there is quite a wait between the initial referral and further contact. More than one family told me they had waited four months between the initial referral and someone contacting them.

One mum said she felt she'd been left 'hanging' after the initial referral and didn't know what was going on.

7.3.3 Even better if...

Overwhelmingly all parents agreed that the involvement of the family is key – there should be good lines of communication between the parents and the therapist. All of the negative points that were identified came from miscommunication or a complete lack of engagement.

Time should be built into the service to enable therapists to meet/talk with the parents directly. Often parents talk to the school and then someone in school relays their interpretation onto the therapist, much can then get lost in the chain of communication – direct communication must be the best way.

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If a child is receiving regular sessions in school, could one out of six routinely involve the parents? The parents could then have an opportunity to have a conversation and also see good practice being modelled.

Parents would need advance notice of these sessions though, particularly if they work.

Consistency across the service – all therapists should follow the same communication pathways with the families. Regular updates through meetings/telephone conversations/texts and or emails should be the norm.

Can there be flexibility as to where the sessions are delivered? Not all children attend their local mainstream school – so travelling to a special school, or out of county setting maybe difficult for parents.

It needs to be clear and transparent who is delivering the sessions, in some cases the therapist has done the initial assessment and then a TA delivers the package. This is not a problem, but parents should be made aware of this, that way they know who to speak to and what training they have had.

Clear exit strategies if the support is going to be withdrawn, there should always be a conversation with the family outlining the ways forward.

A better understanding of different conditions and how these can affect some children's ability to communicate; for example some children will always want to please and therefore will always say yes, when they should be saying no.

Improved communication and contact between the initial referral and receiving the service – if waiting times can't be reduced then at least keep families informed about what is happening and when they are likely to receive some help.

Increased opportunities for career progression for the therapists – one parent felt that many therapists leave Worcestershire because they can only get promotion by working for neighbouring authorities or for themselves.

7.4 Stakeholder's Engagement through Survey

The views of two stakeholders groups were sought through survey. The aims of the engagement were to find out the following:

Whether respondents felt the services currently being offered are meeting children's and family's needs.

Respondent's thoughts on the type and quality of service offered to the children and young people?

What respondent's views are about the types of speech and language therapy services needed for the future?

The survey opened on 10th March and ran until 15th May 2015, at the end of which 43 respondents in total filled the Parent carer's questionnaire and 110 professionals responded. The full report that also contains an executive summary can be found in Appendix 4.

Key finding form the survey are:

The majority of parent carers had accessed SALT. Over 60% of felt that it was Quite Easy or Very Easy to access the SALT service.

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Professional stakeholders were more positive about the progress in general that children have

made from SALT input – two thirds saw this as Good or Very Good. Just 6% thought this aspect was Poor or Very Poor.

Parent carers felt that better training courses and information for parents was seen as a good way to promote Speech Language and Communication via for example walk in group sessions for children or courses for parent carers was a good way to promote good Speech Language and Communication.

Professionals felt that emphasising the development of language in early years of a child's life was the best way to promote good SLC.

Parent carers are notably positive about the following aspects within the SALT service, with a notably higher proportion rating the service Good or Very Good than rating the service Poor or Very Poor:-

o The location of clinics / appointment centres

o The sensitivity of the service towards their child's cultural and religious needs

o The times of clinics / appointments

o Support and advice from your child's early years setting / school

Early intervention was seen as the best way to prevent Speech Language and Communication needs by professionals. Many stakeholders feel addressing issues quickly is vital.

Lack of consistency in terms of the actual therapist seen and appointments being cancelled too frequently were also mentioned

Figure 53: Survey responses

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7.4.1 Identified Gaps from Stakeholders Engagement:

Special Schools want control of their own SaLT budgets.

SaLT about to allocate the core service that Special Schools receive. Currently based on caseloads of children.

Feedback has been that improvements have been made.

Additional training to staff is an expectation of Special Schools, and wants reports for annual reviews etc. Some to purchase independent therapy from private therapists.

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Some schools do this already – and not wanting to duplicate efforts. Can cause duplication of support to children. SaLT find this very frustrating.

SaLT service considers the private therapy model to be one based on dependency not empowerment.

Figure 54: Stakeholder engagement suggested recommendations

8. Alternative Models of Service Provision

8.1 Best practice

8.1.1 The Harrow project (Shaw, Luscombe and Ostime, 1996)

The Harrow Project was a model for a speech and language therapy service of school-based working that was developed in consultation with the LEA, the local Health Authority and with parents. The authors described the planning process, the model of service and an audit of the early stages of the implementation of the model as well as the development of a teacher training programme. A summary of the Harrow Project is detailed below:

Context and Mechanism:

SLTs take regular feed-back from teachers on courses and adjust the content of the course to meet the needs of the teachers

SLTs deliver courses for teachers on how to meet children’s communication needs in collaboration with SLTs

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Outcome

SLTs are more aware of the difficulties faced by teachers

Teachers and therapists develop a shared understanding

Teachers develop increased confidence in reinforcing speech and language therapy aims

8.1.2 The Camden Project

The Camden Project was developed to promote a philosophy of collaborative working with the school as the central point of service delivery. Mechanisms of the Camden Project included: a link therapist for each school; a school-based referral system and each school had an allocation of hours based on need. A survey of the schools conducted at the end of the first term of operation and at the end of the first academic year showed that users were increasingly pleased with the Mechanisms of the project. The description of the Camden Project was very brief, there was no information that could be used to explain or justify the Mechanisms and Outcomes (e.g. progress made by children) were not specified.

8.1.3 Communication Trust

The Better Communication Research Programme (BCRP) conducted specific research into SLCN. A few of the main headline findings and thus recommendations for best practice are listed below;

Support for developing children’s speech, language and communication should be conceptualised at three levels: Universal, Targeted and Specialist. – There should be a range of provision available to meet a range of needs. Even those children with the most specialist needs should benefit from both Targeted and universal approaches.

Services and schools should systematically collect evidence of children’s and young people’s outcomes that include the perspectives of children, young people and their parents, and provide evidence that changes in children and young people’s speech, language and communication are increasing their independence and inclusion. – Both independence and inclusion were highly valued by CYP and their parents/carers and so appropriate measures must be developed in order to evidence these priority outcomes.

A programme of initial and post qualification training is required for teachers in order to meet the varied needs of children and young people with SLCN and to develop the joint planning and implementation of evidence based provision and intervention which is necessary. – Professionals need to be equipped with the necessary knowledge and skills to respond to a variety of needs and need to be supported to do so.

Those responsible for commissioning services for children and young people with SLCN should ensure that the most appropriate model of support is available for every child with SLCN. This requires commissioning from education and health services and ensuring a continuum of services designed around the family, which collaborate effectively. – Due to a lack of consistency, it is a recommended that a 'needs led joint commissioning' approach is taken.

The following examples were provided by the Communication Trust;

8.1.4 Buckinghamshire Case Study

Buckinghamshire took a whole systems approach to joint commissioning for all elements of SLCN. They involved children and young people in all aspects of the procurement process of the services they would be accessing, including interviewing shortlisted organisations. Outcomes as a result were reduced waiting times for SALT services, increased access to services by moving SLT from clinics to schools and the use of impact measures to monitor contracts with providers introducing 'self-selected goals'.

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8.1.5 Every Sheffield Child Articulate and Literate (ESCAL)

ESCAL is a literacy strategy based in Sheffield that "acts as an umbrella for a range of services, projects, initiatives and strategies already being delivered to parents and young children across the city". Its aim is to ensure cohesive working, embedding literacy across services, offering a tiered approach (universal, targeted, specialist) to meet children and young people's speech, language and communication needs.

8.1.6 Stoke Speaks Out

Stoke speaks Out is an initiative that trains and supports parents, carers, practitioners and anyone involved with children. It is available to anyone working with children under 7 and aims to spread the word about communication and language delay in order to create a city wide strategy for communication needs. It also provides a forum for practitioners to network, share ideas and even offers an accreditation to settings who are 'communication friendly'.

8.1.7 Early Language Development Programme (ELDP)

The ELDP was a national training programme led by ICAN that aimed to increase knowledge and awareness of speech, language and communication needs in 0-5 year olds. The programme built on learning gained through other programmes such as Every Child a Talker (ECaT). 998 lead practitioners were reached and training was then cascaded from these practitioners to other professionals. It was found that this cascade approach worked well as it reached out to wider audiences and allowed more professionals to engage with and use the training in day to day practice due to an increased awareness and confidence with identifying and assisting children with speech, language and communication needs.

8.1.8 Wellcomm Toolkit

'The Wellcomm Toolkit is a developmental monitoring tool for children aged 6 months – 6 years, which identifies a range of SLCN and has accompanying intervention materials. The assessment is conducted interview-style with teacher-pupil interaction and paper recording sheets, which can then be input to a computer interface for pupil and class profiles'. Although the toolkit is beneficial when monitoring a wide age range and tracking progression, it is not technologically advanced, widely used or robustly evaluated and is very costly compared to similar toolkits, such as Language Link.

8.2 Snapshot of models from some other local authorities

8.2.1 Essex CCG

In Essex CCG commissions the therapies, ECC commission any gaps to meet the legal requirement and some schools commission too. In Essex the coverage is good in South but ECC top-up in other areas Essex CCG contracts have been in place since before PCTs became CCGs and therefore they are finding it difficult to unpick all the arrangements between CCGs, Essex CC and schools and are looking at developing options to potentially commission things differently going forward. In their health contracts there are other therapies included e.g. Paediatrics rather than just speech and language therapy which makes it difficult to un-pick how much is being spent. In Essex they are trying to ascertain the CCG spend as it is not held centrally and are currently bridging a gap between legal requirement and the CCG commissioned therapies. Schools have funding to meet need locally and if not have to apply for additional money through usual processes. Some schools meet out of their own budget.

8.2.2 North Somerset CCG

North Somerset SALT covers 0-19 years of age if the child has complex needs and has a North Somerset GP. Children without complex needs are seen in the 0-11 age bracket for language difficulties. They have a joint therapies service specification; however, the services are detailed separately in the document. All SALT in North Somerset through Weston Area Health Trust is CCG funded on a block contract. The Local Authority funds a full time band 6 SLT in Children's Centres and a half time Communication Assistant. The Special

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Schools, Baytree and Ravenswood fund a small amount of Assistant time in their schools. There is no experience of personal budgets in North Somerset to date. They currently use programmes and outcomes based on EKOS to measure targets set and are in the process of re-commissioning the service. The population within North Somerset CCG area for 0-18 year olds is 45,000.

North Somerset's standard average waiting time for Speech and Language services is 13 weeks, however at this time the average waiting time from referral to appointment is less than 13 weeks. In financial year 2014/15, North Somerset accepted 536 referrals to the speech and language service, with a total of 7 workforce WTE.

8.2.3 St. Helen's CCG

The Speech and Language Therapy service in St Helens is commissioned by the Clinical Commissioning Group (CCG) and provided by 5 Boroughs Partnership NHS Foundation Trust.

A Language and Social Communication team (LASC), part of St Helens Council Children’s Disability Services, provide a language and social communications therapy service for children in mainstream schools in St Helens. The service is funded by schools and is complementary to the Speech and Language service provided by 5 Boroughs Partnership. Both the LASC team and SALT team receive referrals from schools and can provide the same individual with support. There were 1,304 appropriate referrals made to the speech and language therapy team in the year 2013/14.There were 497 referrals to the LASC team from September 2011 to July 2013. These were from 75 schools in St Helens, 70 of which required intensive support. The national target of 18 weeks from referral to treatment was unmet in 2013 with some waiting as long as 42 weeks. In 2014, waiting times from referral to initial appointment ranged from 9-12 weeks with an average of a 10 week wait.

Mill Green and Lansbury Bridge are specialist schools which the Speech and Language Therapy team deliver to. The school commissioned services are separate from the LASC and SALT teams

8.2.4 East Sussex County Council

East Sussex has been with their current provider since 2012. The SALT service is integrated with physiotherapy and occupational therapy. In 2013, the population of 0-19 year olds was 117,037. Some schools have their own speech and language therapist which is DSG funded.

East Sussex's standard average waiting time for Speech and Language services is 18 weeks for an initial assessment and children on average start therapy within 8 weeks of assessment. In financial year 2014/15, East Sussex accepted approximately 1000 referrals to the speech and language service, about 250 per quarter. Referrals are directed to a central coordination point. The referral process includes; receipt of referral, acceptance of referral based on further information obtained prioritisation to waiting list and allocation to an appropriate therapist.

8.2.5 Hampshire County Council

The SALT Service was funded by Hampshire County Council from the Local Authority Block from April 2012. Funding from the Local Authority Block will cease as part of the Children’s Services budget savings required for 2015/16.

In the year (2013/2014) 430 referrals to the service were accepted. The service covers 26 schools, 10 of which receive no NHS SLT service and many of those who do, do not have a service that will take referrals for pupils above Year R or Year 1.

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8.2.6 How Worcestershire Compares with its Statistical Neighbours

Figure 55: Comparison with statistical neighbours

Area Spend on SALT Population of 0-18 year olds Accepted Referrals per year

Worcestershire CC * 121,779 2297

East Sussex CC * 117,037 1000

*Some of the data in Figure 56 has been supressed as this data is commercially sensitive.

There was limited budgetary information to benchmark our current service against; however, based on the information received from East Sussex, it suggests that our funding figure is on a par with an area which has a similar population.

9. Conclusion and Recommendations

1. The commissioning of the prevention and early intervention element of the SALT service should be revised to ensure better use of early intervention investment and improved integration with wider early intervention/early help services.

2. There should be a strong focus on coverage across early year's settings (considering designs around language classes, workforce development and timely access to a service or advice and support) as evidence has shown the need for a focus on 0-5's, early intervention .

3. The revised SALT service specification will address an improvement in average waiting times and outcomes measures. This will consider a specific KPI around average waiting times. The design phase will consider models for timely assessment and intervention.

4. Make clear to schools and other settings the level of service that they can expect from the commissioned speech and language service. Also outline additional support over and above the core service that is available for schools and settings to purchase.

5. Join up commissioning with WCC education commissioners in order to utilise all funding in the most efficient manner, and deliver the SEN Reforms effectively.

6. Implement the use of the CHAT assessment toolkit within YOS for every young offender, to be able to clearly identify communication needs. Better recording from the CHAT assessment data will help to identify needs earlier. The new service specification will outline the approach between the Youth Offending service and the Speech and Language Therapy service, with a robust KPI, to achieve better outcomes for Youth Offenders with speech, languge and communication needs.

7. Train health visitors to be able to undertake further screening and early intervention to avoid unnecessary attendance at drop in sessions and escalation to specialist interventions. This would build on existing training that has taken place. Ensure that refresher training for health visitors is available, due to the positive impact that SALT training appears to have produced and ensure that training continues to be avaialable.

8. As a result of the analysis of postcodes of Talking Walk-in attendees, drop-ins at universal children's centres, and some targeted settings should cease. It is recommended that the alternative provision includes information, advice and guidance. The additional time available at the end of clinics within these sites can then be utilised flexibly to address pressures in the service.

9. Make available a range of information for families via a website and other mediums to promote prevention and early intervention.

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10. At the time of writing this Speech and Language Needs Assessment, a review of the Neuro-

Developmental Pathway has commenced and the findings of this may inform the design of the future Speech and Language therapy service.

11. The design phase should include families and stakeholders.

10. Outcomes Expected

Better access to speech, language and communication services for all children and young people and equity of access for different groups - measured by improved waiting times, referrals reflecting the needs identified in the population.

the experience of services will be good – measured by experience of service tools

services will be able to demonstrate improved speech, language and communication of the service users as a result of receiving a service, using by valid clinical outcomes measurement tools.

fewer children and young people will require a referral to the speech, language and communication service because their needs will be met at an earlier stage.

more children and young people will experience a good transition to adult services when required, measured by experience of service across transition.

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Additional Information

Approvals

Name Signature Title Date

Project Sponsor:

Strategic Commissioner: Early Help & Partnerships

29/02/16

References

Children's Trust (2014-17) Children and Young People are helped at an early stag, Worcestershire's Children and Young People's Plan.

Department of Education (2011) Investigating the role of language in children’s early educational outcomes.

Communication Trust (2011)

Thistleton, Lisa (2008) University of Birmingham Thesis.

Nacro (2011) Speech, language and Communication Difficulties – Young people in trouble with the law.

I CAN Talk (2011)

NICE (2014)

Bercow Report (2008)

Roulstone et al. (2011)

Office of Communication Champion (2011)

Snowling et al. (2010)

Feinstein and Duckworth (2006)

Snow (2000)

Cohen et al. (1998)

Bryan (2008)

Gutman and Brown (2008)

Clegg et al. (1999)

UK Commission for Employment and Skills (2009)

Hart and Risley (2003)

Waldfogel and Washbrook (2010)

Blanden (2006)

ONS Census (2011) Based population projections and DfE estimated prevalence rate per 1000.

Department for Education (2013)

Keypas (n.d) Percentage of children achieving 6 or more within Communication, Language and Literacy Skills.

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Gascoigne (2008) The balanced system.

Law et al. (2010)

Royal College of Speech and Language Therapists and Association of Speech and Language Therapists in Independent Practice (2011)

ICAN Report (2006)

Public Health Outcomes Framework (2012-13) School Readiness

Early Help Needs Assessment (2015)

Law, Garrett and Nye (2005)

Ibid

Wright (1996)

Law et al. (2002)

Royal College of Speech and Language Therapists (1996)

Shaw, Luscombe and Ostime (1996) The Harrow Project.

Appendices

Appendix 1: SALT Service Specification

Appendix 2: Talking Walk-In and ECAT Final Report

Appendix 3: Children and Families Engagement Full Report

Appendix 4: SALT Engagement Survey Results - Full Report

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joint commissioning services to children and young people ... · through commissioning of a model...

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