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A Scottish Executive Review of Speech and Language Therapy, Physiotherapy and Occupational Therapy for Children and Speech and Language Therapy for Adults with Learning Disabilities and Autistic Spectrum Disorder

Part 5 Speech and Language Therapy, Physiotherapy and Occupational Therapy for Children

1. In this section of the report, we summarise the information gathered relating to the supply, demand, funding, organisation and management of Speech and Language Therapy, Physiotherapy and Occupational Therapy for children. The data are reported more fully in the appendices.

2. The statistical information reported here was gathered through surveys of NHS and Local Authority services in which therapists work. The review received almost 100% return rate from the NHS. A lower return rate of 72% was received from Local Authorities. As this information is partial it should be treated with some caution.

CURRENT PATTERN OF THERAPY FOR CHILDREN

3. Therapies for children are either delivered by therapists who work solely with children or therapists who work with both children and adults. In the report we refer to these as 'paediatric' and 'generic therapists' ⁱⁱⁱ respectively. These therapists are either employed by NHS Boards, Local Authorities, voluntary organisations or grant-aided schools.

4. The majority of Speech and Language Therapists, Physiotherapists and Occupational Therapists working with children are employed by NHS Boards. A diversity of management arrangements are in place within the Trusts. The proportion of services for children provided by paediatric therapists as opposed to generic therapists in the NHS varies from profession to profession and from area to area.

5. There are a significant number of Occupational Therapists employed in Scotland's 32 Local Authorities. However, the majority of assessments and service provision undertaken by Occupational Therapists are provided for adults rather than children. There are only a small number of paediatric specialist posts in Local Authorities in Scotland and services for children are frequently provided by generic therapists. A recent report stated that the main role undertaken by generic Local Authority Occupational Therapists continues to be the assessment and provision of equipment and adaptations for disabled people. This is despite the fact that Occupational Therapists have a wider set of skills in rehabilitation. ²⁶

6. A small number of paediatric therapists are employed by voluntary organisations or grant-aided schools.

7. As the majority of Speech and Language Therapy, Physiotherapy and Occupational Therapy for children is provided by NHS therapists, more detailed data relating to the supply of and demand for these therapies are reported below than is the case for Local Authorities and voluntary organisations.

SUPPLY OF SPEECH AND LANGUAGE THERAPY, PHYSIOTHERAPY AND OCCUPATIONAL THERAPY FOR CHILDREN

Numbers of therapy posts established to provide services to children

NHS Therapy Posts

8. The table below shows the number of NHS Speech and Language Therapy, Physiotherapy, Occupational Therapy and clinical support worker posts established to work with children in Scotland. More detailed information about posts can be found in Appendix C. Paediatrics is a relatively small specialist area in Occupational Therapy and Physiotherapy but is the main area of work for Speech and Language Therapists.

9. There are approximately 137 posts established for state registered Occupational Therapists, 165 posts for state registered Physiotherapists and 520 posts for state registered Speech and Language Therapists in NHS Scotland to provide a service to children.

10. We estimate that salary costs for NHS OTs are just under 3.4m, for NHS PTs are just over 4.2m and for NHS SLTs are just under 13.7 million (see Appendix F).

Table 0:1 Numbers of NHS Speech and Language Therapists, Physiotherapists, Occupational Therapists and clinical support workers in Scotland

Notes:
All posts are recorded as whole-time equivalents(WTE).
NHS Physiotherapy
Grampian Primary Care Trust generic posts are not included, Tayside Primary Care Trust data were not supplied.
NHS Speech and Language Therapy
Tayside Primary Care Trust data were not supplied.

11. Numbers of NHS therapy posts established per 100,000 population were calculated (see Appendix D). While it would be inappropriate to make any comparison between professional groups, it is noteworthy that variations in numbers of posts per 100,000 population within each profession are substantial. For example, numbers of posts for state registered PTs range from 2.42 posts in Argyll and Clyde to 5.79 in Shetland. It is difficult to make an assessment of the appropriateness of the levels as we are unaware of any benchmarking exercise that has been undertaken in paediatric therapy. However, there is clearly some inequity between NHS Board areas if judged on population figures alone.

Local Authority posts requiring an Occupational Therapy qualification

12. A recent Scottish Executive statistical bulletin reported a total of 39 WTE posts for senior Occupational Therapists and 289 WTE posts for Occupational Therapists in the 32 Scottish Local Authorities. The majority of these will provide a generic service to both adults and children. ²⁷ The same bulletin reported that there were 200 OT assistants in Local Authorities in Scotland.

13. There are also a number of OTs employed under different titles. For example, of 1,833 FTE in 29 local authorities, 164 were OTs, representing 9% of the figure available. ²⁸

14. It has proved difficult in this review to determine the number of OT posts ^iv established in Local Authorities to work with children. Of 32 questionnaires sent to Local Authority managers, 23 were returned. However, information was not provided by some of the largest Local Authorities in Scotland. The available data, therefore, relate to authorities in which less than 50% of the population of Scotland is located. Data from both rural and urban authorities were not supplied.

15. From the information supplied, it appears that the number of OT posts established in Local Authorities to work specifically with children is low. Only six of the 23 Local Authorities which responded to the survey reported having paediatric posts which require an OT qualification. There are a total of 6.6 paediatric posts in these six authorities. In addition, the survey identified 203.1 WTE posts, in 21 authorities that gave this breakdown, requiring an OT qualification and working with both children and adults. Most authorities were unable to estimate the proportion of time spent by these OTs working with children. Seven authorities made estimates of between 2.2% and 25%. This suggests that the total proportion of these 203.1 generic posts working with children in the 21 authorities could be anywhere between 4 and 51 WTE posts. In addition, a small number of authorities employ assistants who provide services to children.

Therapy posts in the voluntary sector or grant-aided schools

16. There are a small number of therapy posts funded or part-funded by voluntary organisations or grant-aided schools. Some of the therapists occupying these posts are employed directly by the voluntary organisation or school. Others are employed by an NHS Trust and are contracted to provide services to users of the voluntary organisation or pupils at the school.

17. Four of the seven grant-aided schools in Scotland directly employ therapists. Data were available on three of these four schools and they employ a total of 4.8 OTs, 7.9 PTs and 4 SLTs.

18. Two of the schools which directly employ therapists are managed by Capability Scotland. We are aware that Capability Scotland also provides therapy to children in community settings. We were unable to establish the numbers of community therapy posts but believe they are small.

19. There are a number of specialist services in Scotland providing assessment and advice in relation to Alternative and Augmentative Communication aids. These include Scottish Centre of Technology for the Communication Impaired (SCTCI) in the West of Scotland, KeyComm in Lothian, Technological Assessment and Support for Special Children and the Curriculum (TASSCC) in Aberdeen and Fife Assessment Centre for Communication through Technology (FACCT) in Fife. These services all employ a small number of SLTs and we aware of one service that employs a part-time OT. The services are funded either by Local Authorities, Health Boards or they are joint funded.

20. There are a small number of therapists employed by the National Autistic Society in Scotland and The Scottish Society for Autism. There are also individual therapists employed by UK charities to provide a 'regional' service throughout Scotland. The charities include Whiz Kids, a charity providing mobility equipment to disabled children.

21. It proved difficult to find out about therapists working in the voluntary sector. This may be because they are not as closely linked into formal networks as those working in the statutory sector.

Skill Mix in NHS Services for Children

Career structure for NHS therapists working with children

22. Most of the NHS Occupational Therapy and Physiotherapy posts providing a service to children (83%) are graded either at senior l or senior ll level. Most NHS Speech and Language Therapy posts are graded at band 2 (75%). These are grades at which therapists would be expected to work independently in a range of community settings. There are few posts established for new graduates, particularly in Physiotherapy (see Appendix E). This appears to be because new graduates usually work under the close supervision of an experienced therapist, for example, on a hospital ward or in a special school that has a high level of therapy input. This
on-site supervision is not easily available within community paediatric services because of staffing levels.

Clinical support workers in NHS services for children

23. All three NHS professional groups reported the important role that clinical support workers play in delivering an effective and efficient service. Occupational Therapy traditionally has the highest ratio of clinical support worker posts to state registered therapist posts when compared to other Allied Health Professions (AHPs). The ratio across all clinical areas is 1 clinical support worker for every 4 state registered therapists. The picture in paediatric services is significantly different with a ratio of 1 clinical support worker for every 13 state registered therapists. ²⁹ Physiotherapy also has a slightly lower ratio of clinical support workers to state registered therapists in this speciality. Speech and Language Therapy on the other hand has higher numbers of clinical support workers working with children than in other specialist areas.

24. There is evidence that pressure of work affects skill mix. For example NHS Physiotherapists and Occupational Therapists said that staff shortages make it difficult to supervise and support clinical support workers.

Administrative support to NHS therapists working with children

25. It appears that the level of administrative support for NHS therapists varies from area to area but is often inadequate. Managers were concerned that therapists are tied up with administrative tasks. Many therapists type their own reports and set up their own appointments. Professional advisors on the review steering group estimated that 30% of a therapist's time can be spent undertaking administrative tasks. Frequently, when new therapist posts are funded, no additional clerical support is made available and so administrative support is spread increasingly thinly. In addition, some services have an inadequate Information Technology infrastructure, such as word processing and e-mail facilities, in order to carry out their work efficiently.

Recruitment and Retention Issues

Vacancy rates within NHS posts

26. All three NHS professions have high vacancy rates for NHS paediatric therapists in some areas (see Appendix G). For example, OT vacancy rates were 20% or more in three areas, PT vacancy rates were above 20% in five areas and SLT vacancy rates were above 20% in two areas. These rates are likely to have a significant impact on the level of service that can be provided.

27. That said, the number of posts vacant in some cases is relatively low making the solution more straightforward. For example, the Occupational Therapy service in Borders has a 29% vacancy rate representing a significant reduction in service provision. However, the service needs to recruit only one whole-time equivalent OT to restore a full service to children in the Borders. Similarly, Shetland Physiotherapy service has a 62% vacancy rate and needs to fill 0.8 of a post.

Factors influencing NHS vacancies

28. Several managers referred to the highly specialised nature of work with children and the extra skills needed by staff when working independently in community settings. Managers from all three professional groups reported that NHS vacancies can persist as there is too small a pool of experienced therapists to draw upon to fill senior l, senior ll and band 2 posts. Half of Occupational Therapy vacancies, two-thirds of Physiotherapy vacancies and more than three- quarters of Speech and Language Therapy vacancies had been unfilled for three months or more.

29. In addition, managers stated that there are too few training opportunities available to develop the pool of experienced therapists. Examples given included too few basic grade paediatric posts, a lack of rotational posts, limited numbers of senior ll training posts for Physiotherapists in specialities such as paediatrics and neurology, too few paediatric fieldwork education placements for student therapists and too little continuing professional development for therapists wishing to move between specialities.

Recruitment and retention in remote and rural areas

30. Remote and rural areas were particularly affected by high vacancy rates. Rural areas and island communities stated that they tend to have an even smaller pool of therapists to draw upon and it is difficult to attract new therapists into the area. Managers reported that high unemployment rates in some of these areas make it less attractive for therapists to move there, as their partners are unlikely to be able to secure employment. Managers also stated that the cost of living on islands is higher and therapists can feel isolated and lack peer support. Rural areas that are within commuting distance from cities reported that they are able to recruit therapists who choose to live in the city and work in the country. However, high travel costs make retention of these therapists difficult.

The impact of NHS maternity and sick leave rates on supply

31. A major issue across all three professional groups is the additional pressure placed on the service due to maternity leave and sick leave. In paediatric OT, 98% of the workforce is female and more than half of the workforce is under 35. In paediatric PT the picture is similar with more than 95% of the workforce being female and approximately one-third of PTs being under 35. Similarly, in paediatric SLT 98% of employees are female and just over half are aged 40 or under.

32. One OT service with eight WTE posts reported that over the past 12 years there had not been a single year when fewer than two staff took maternity leave at some point. Managers stated that this increases pressure on staff in an already stretched service. In addition, managers stated that many therapists choose to come back to work on a part-time basis following the birth of a child. They pointed out that while the introduction of positive employment policies and practices is to be welcomed, the implications of maternity and sick leave for workforce planning need to be taken into account.

33. Approximately two-thirds of NHS Board areas had at least one instance of long-term sickness in 2001-2. Long-term sickness was defined as an absence of four weeks or more. One PT service had six instances of long-term sickness last year and one OT service had five instances of long-term sickness last year, that is at least five or six months of the year where the service level was reduced due to sickness. These were exceptional cases.

34. All three groups stated that temporary posts to cover absences are unattractive and difficult to fill. Locum posts are both an expensive option and it is often difficult to find a locum with the right level of expertise. These problems are compounded by the fact that there can be delays in releasing money to recruit to temporary posts even when the post is funded under an Education contract.

Tackling supply shortages in the NHS caused by temporary absences

35. Managers called for devolved staffing budgets, contingency funds to cover maternity and sick leave, supernumerary staff to cover fluctuations in staffing, and automatic or emergency approval of funding to cover maternity leave from day one of a maternity leave absence rather than after 18 weeks.

36. Other suggestions to deal with pressures of reduced supply in all three professional groups included allowing overtime or weekend working at enhanced rates for any staff who want additional hours, and developing a bank of therapists to draw on. It was suggested that the NHS boards could co-ordinate setting up a bank system and contact potential bank therapists through professional registers.

Tackling supply shortages in the NHS through the introduction of family friendly policies

37. Many managers reported that they had had some success in retaining existing staff through the introduction of family-friendly policies such as term-time-only contracts, flexible working hours, part-time and job-share opportunities and parental leave policies. While these were seen as positive ways of retaining employees, managers pointed out that they have financial and organisational implications for a service. Managers face the challenge of maintaining continuity within the service and good communication when so many employees work part time. They explained that restructuring the service to accommodate flexible working could result in gaps in service at certain times of the year or week. There is a danger, once several posts have been reduced to part-time hours, that a few hours will be uncovered but that these will be too small to make up an attractive part-time post. This can increase pressure on the staff team as a whole.

Tackling supply shortages in the NHS through training initiatives

38. There was agreement across the three professional groups that good training programmes, induction programmes and continuing professional development opportunities were necessary to retain staff. Good supervision and support from within the team were also seen as important. Speech and Language Therapy managers in four rural areas highlighted the importance of having good links with universities by offering student placements, teaching on courses and employing students as clinical support workers during holidays.

39. Physiotherapy managers in four areas reported that they had had some success in tackling recruitment and retention problems through the introduction of rotational posts. There are rotational posts for basic grade Physiotherapists in one area in Scotland and rotational posts for senior ll Physiotherapists in eight areas in Scotland. Periods of rotation are between six and 12 months. There are far fewer rotational posts in Occupational Therapy, one area having a rotational basic grade post and two having rotational senior ll posts. These posts rotate every seven to 18 months. Only one Speech and Language Therapy service reported that it 'sometimes' has rotational posts.

40. Some Speech and Language Therapists also reported that generalist posts that cover several areas such as adult services, paediatrics and learning disabilities are popular and allow therapists to developed a broad set of skills before later specialising. Approximately 13% of SLT provision for children is delivered by generic therapists in Scotland and in some areas the numbers are substantially higher. For example, in Shetland the service is entirely delivered by generic staff and in Highlands 53% of the service is delivered by generic staff. This contrasts with OT and PT which is delivered almost entirely by paediatric therapists.

Recruitment and retention issues relating to Local Authority Occupational Therapy posts

41. From the figures provided by 23 Local Authorities that replied to the survey it appeared that recruitment and retention of Local Authority OTs was less problematic than in the NHS. Only seven authorities reported vacancies in OT posts providing a service to both children and adults. These vacancies represented a 6% vacancy rate. There were no vacant paediatric posts.

42. However, only three authorities stated that they have not experienced recruitment and retention difficulties. The others stated that recruitment and retention is problematic, particularly the recruitment and retention of experienced OTs and part-time employees. Temporary posts are also difficult to fill. They suggested a number of factors contributing to these difficulties including shortages of OTs across all sectors in Scotland, high caseloads, the generic nature of caseloads in Local Authorities and a perception that Local Authority OTs carry a higher level of responsibility. Remote and rural areas stated that they face particular difficulties attracting qualified staff and providing good support and supervision to therapists.

43. The most frequently cited factor contributing to recruitment and retention difficulties was the current unfavourable pay and conditions for OTs in Local Authorities in comparison to NHS employees.

The relationship between supply of therapists and quality of service

44. Managers pointed out that an inadequate supply of therapists affects the quality as well as the quantity of service provision. For example, continuity of care can be negatively affected.

45. Conversely, SLT managers reported that increased supply has affected quality positively. For example, one service explained that increased staffing levels have led to a broader range of skills being available within the team allowing peer support and review arrangements to be implemented.

DEMAND FOR SPEECH AND LANGUAGE THERAPY, PHYSIOTHERAPY AND OCCUPATIONAL THERAPY FOR CHILDREN

46. The table below summarises the numbers of children referred to therapy in 2001-02, discharged from these services in the same year, on the caseload of therapists in Scotland in April 2002 and on a waiting list to see a therapist in April 2002 (see notes in Appendix H).

Table 0:2 Demand for NHS OT, NHS PT, NHS SLT and Local Authority OT for children in Scotland in 2001-02

NB: LA figures represent less than 50% of the population

Referral information

47. Rates of children referred to NHS therapists per WTE post and per 1000 population have been calculated. Data on NHS referral rates can be found in Appendix I. These rates varied considerably from area to area. For example, there were 5.5 children referred to PT per 1000 population in Borders and 0.4 children referred to PT per 1000 population in Orkney. It is unclear whether these variations result from different levels of need in certain areas or from different perceptions of what the service can offer.

48. Although the numbers of children referred to Local Authority OTs are lower than those made to NHS colleagues, they are still substantial, especially as the figures are for approximately half of Scotland.

49. Grant-aided schools do not have referrals as such as all of the children attending the school would be considered to be part of the therapists' caseload.

50. The majority of NHS Speech and Language Therapy referrals come from Health Visitors. The majority of NHS Occupational Therapy and Physiotherapy referrals come from Staff Grade/Community Paediatricians or Consultants in hospitals. Small numbers of referrals comes from GPs.

51. Occupational Therapists reported difficulties educating referrers to refer early and to provide appropriate information for prioritisation, e.g. about the functional aspects of the child's impairment.

52. All NHS OT and PT managers stated that they have a procedure in place to prioritise referrals. Only three SLT managers stated that they do not have such a procedure. Managers were asked whether the procedure was devised locally or followed guidance from either a Special Interest Group or professional body. The majority, but not all, said that procedures followed guidance from either a Special Interest Group or professional body.

53. Of the NHS services we interviewed, most, but not all, offer a child an initial assessment within six to eight weeks, the standard set by the waiting list initiative fund. Some services screen referrals by telephone to determine the child's level of priority for an initial assessment. Following an initial assessment a child could:

• immediately receive treatment/direct intervention

• immediately have indirect intervention (e.g. training a classroom assistant in positioning the child)

• go on a waiting list for direct or indirect intervention

• be placed on review for six months - this may be done if the therapist suspects that the problem the child is experiencing is likely to diminish without therapy as the child develops.

54. Some NHS therapists, therefore, operate two waiting lists, one for initial assessment and one for interventions.

Waiting list information

55. Information about waiting lists can be found in Appendix J. In April 2002, there were 1,809 children waiting to see an NHS Occupational Therapist, 300 children waiting to see an NHS Physiotherapist and 3,472 children waiting to see an NHS Speech and Language Therapist across Scotland and 116 children waiting to see an OT in 22 Local Authorities.

56. Managers were asked to state the longest time that a child currently on the waiting list has waited for a service. Some children are experiencing unacceptable waiting times, particularly those waiting to see an NHS OT. Waiting times also varied from service to service within an NHS Board area and even within one service. For example, Lomond & Argyll Primary Care Trust SLT service stated that children are generally seen in six to eight weeks but in rural Argyll it is longer (in Tiree children wait up to 14 weeks and in Tarbet up to 31 weeks).

57. Two areas had children who had been on the waiting list to see an NHS OT for two years. In one of these areas the longest wait resulted from a waiting list being inherited from a service previously contracted out to a voluntary organisation. One local authority and four NHS services had children on a waiting list to see an OT who had waited for at least one year, and one NHS service had a similar experience for a PT. NHS managers reported that children requiring group therapy often wait for longer periods as it takes time to find enough children with similar needs who can be treated together.

58. The SLT service in Greater Glasgow's Yorkhill NHS Trust is the only SLT service in Scotland that employs bi-lingual co-workers. These are clinical support workers who speak a community language and work with SLTs to make the service accessible and appropriate to people from minority ethnic communities. However, the service reported that waiting times can be longer for families whose first language is not English.

59. It should be noted that the longest wait is not the same as the typical wait and many
children are seen sooner. In some areas longest waiting times were very low. This was particularly true of PT services where new patients are taken on at the expense of level of input for
existing patients.

Current cases and discharges

60. A total of 6903 children were on the caseload of NHS OTs, 8,794 on the caseload of NHS PTs and 40,591 on the caseload of NHS SLTs in Scotland in April 2002. In addition, there were 884 children who were current cases of OTs in 20 Local Authorities, so current cases could be potentially double that figure.

61. NHS current cases are presented per WTE therapist in Appendix K. These figures do not represent an average caseload per therapist as caseloads may vary between grades of staff. Caseload size might depend on level of management responsibility, level of experience or nature of work undertaken. Some therapists, therefore, will have higher numbers on their caseload than the figures reported and others will have lower numbers. The figures are intended to allow comparison of the relative demands placed on services in each area. In some areas numbers of current cases per WTE are very high. For example, in Borders there were 134 current cases per WTE OT and 168 current cases per WTE PT. In Orkney there were 236 current cases per WTE SLT. These figures raise questions about the scope and level of service that can be offered to children when demand is high.

62. There is evidence that 'current cases' are defined differently by NHS therapists in different areas and even within a single service. The term may include children who are being assessed, children who are receiving intervention and children who are 'under review' or 'passive/dormant cases'. The proportions of each category of child will vary. Therapists in most of the areas we visited are given clinical autonomy to manage their caseload, however, the manager would use supervision to ensure equity of service across the area and fairness of work distribution between the therapy team. Some services have a standard system in place such as SMART objectives (Specific, Measurable, Achievable, Realistic, Time-limited) or 'Care Aims' to set goals, monitor the service's progress with children and evaluate the effectiveness of interventions.

63. It is not clear from our investigations what constitutes a 'passive/dormant case' but we did hear examples of therapists who will keep a child on their caseload as a passive case yet provide no input. In some cases this decision was influenced by parental pressure to keep the child on the therapists caseload. Some services encourage therapists to discharge children and ask for a re-referral if needed. Others do not. Managers reported that some therapists do not discharge children as it is difficult to get back into the system if further therapy is needed.

Management of demand

64. Overall, the pattern of demand for therapy in the NHS appears to be one of rising numbers of referrals, higher numbers of referrals than discharges and even higher numbers of current cases indicating increasing pressure on therapists to meet demand (see table 5:2).

65. Both NHS therapy managers and purchasers of SLT in Education departments described increased need for services for children with complex health needs and children with autism. They highlighted the fact that these developments place growing demands on both education and health services and the need to work together.

66. There were differences evident in the way that demand for therapy is managed by the NHS. For example, Occupational Therapy in NHS Borders had high numbers of referrals, high current cases but low waiting list numbers. Occupational Therapyvice in NHS Glasgow on the other hand, had lower referrals, lower current cases but higher waiting list numbers and times. Where there are limited resources the choice may be between providing a minimum service to as many children as possible or providing intensive services to children in greatest need.

67. Some NHS managers expressed concern about the inadequacy of data collected locally and nationally. They explained that most NHS Trusts collect information on new referrals, re-referrals and face-to-face contacts only.

68. A small number of Local Authority OTs stated that their ability to meet demand from children was hampered by the large volume of adult referrals to what is a primarily adult service.

FUNDING OF CHILDREN'S THERAPY

SOURCES OF FUNDING

Sources of funding for NHS therapy

69. The majority of NHS Occupational Therapy and Physiotherapy posts are funded by NHS Boards (around 97% and 95% respectively). The remaining posts are funded from a range of sources including the Excellence Fund, the Innovation Fund, a Sure Start grant, an Education Department, a Social Work Department, a private special school, a grant-aided school and a voluntary organisation (see Appendix L).

70. The pattern of funding is different for Speech and Language Therapy. Approximately two-thirds of NHS SLT service for children across Scotland are funded by health (64%) and one-third by Education (34%). Only 2% are funded from other sources. However, these figures vary considerably from area to area. In Dumfries and Galloway as little as 11% of the service is funded by Education, whereas as much as 91% is funded from this source in Shetland. A high proportion of the service in Greater Glasgow is funded by Education at 60%.

71. Sources of funding for SLT other than in health and education include grants from Sure Start, the Excellence Fund, the Health Improvement Fund, the Innovation Fund, Changing Children's Services Fund as well as funding from independent schools, community schools, voluntary services and private contracts.

72. There are small but significant numbers of NHS therapy posts being contracted by grant-aided schools in one NHS board area. For example, 3.43 of the 33.4 WTE PT posts in the area are funded through these contracts.

Sources of funding for OTs in Local Authority services

73. In the 23 Local Authorities which returned the questionnaire, only two indicated that posts are funded from sources other than mainstream Local Authority budgets. In one authority 0.6 WTE post appears to be funded by Capability Scotland and in another 0.6 WTE post is funded by a Sure Start grant.

Pay and conditions

74. There are some differences in pay for each of the three professions.. The situation between OTs employed in the NHS and those employed in LAs has fluctuated over the years, and at times salaries have been higher in LAs. It is current position that NHS salary is higher. It should be noted that the role of the OT may vary both within, and between, Local Authorities.

75. NHS OTs and PTs, but not SLTs, are awarded an additional payment if they provide supervision and support to students undertaking a clinical placement or fieldwork education placement, although this varies across Scotland. In some NHS localities the payments go to departments rather than individuals, and in other areas, are not visible at all. In local authorities, payments are in place for Social Work student practice placements, but not for Occupational Therapists.

Views of NHS managers and Education purchasers about the mechanism of funding Speech and Language Therapy Service through Education Departments

76. Speech and Language Therapy managers across Scotland were surveyed to seek their views about the current mechanism by which therapy for children is funded by education departments. In the majority of areas this applied to SLT only with the exception of Fife where some SLT, OT and PT are funded through this mechanism. This issue was also pursued in interviews with Speech and Language Therapy managers and purchasers from Education.

77. Some important benefits of the funding of therapy for children through Education departments were identified by SLT managers including increased staffing levels and greater dialogue between Health and Education agencies. However, managers in all areas identified some problems with the mechanism, as did the Education Department purchasers.

Level of service funded by Health and Education

78. Education contracts were intended to fund the provision of an 'enhanced' Speech and Language Therapy service, i.e. additional to that provided by NHS Trusts. SLT managers did report an increase in staffing levels when the mechanism was first introduced. However, both managers and purchasers were concerned that this 'enhanced' service is slowly being eroded.

79. Some NHS managers noted that there had been no comparable service developments in therapy funded by health despite increasing demands. This has led to many Speech and Language Therapy posts being funded through external contracts. SLT managers were also concerned that cost of living rises from Education departments are not keeping up with real costs leading to further reductions in the service.

80. Purchasers in Education Departments expressed concern about the lack of clarity about which posts and, therefore, which therapies are being funded from Health or Education sources. They explained that they found it difficult to identify 'additionality', that is, which part of the Speech and Language Therapy service was being provided over and above the baseline service provided by the Trust. Purchasers in one area also expressed concern about an NHS Trust recently reducing the number of therapy posts it funds explaining that this has an impact on the Education Departments' ability to develop therapy to children with special educational needs. The perception of all of the Education department purchasers to whom we spoke was that therapy input is low down on the list of priorities for NHS Trusts. This was also the view of some of the therapists that replied to the surveys. This is surprising as children's services are one of the priorities identified in Our National Health. ³⁰

81. Finally, agencies' responses to the recent Speech and Language Therapy realignment exercise has threatened the level of service. There has been no increase in the grant made to Education departments to meet the cost of regrading and Local Authorities and Trusts are responding to this issue in a variety of ways. Some Trusts are meeting the extra costs. Some Local Authorities are meeting the extra costs. Some services are cutting posts or grades to stay within the
existing budget.

Ensuring equity in SLT provision

82. Both NHS managers and Education department purchasers expressed grave concerns about the link between Education department funding for SLT and Records of Needs. They explained that each Local Authority implements Records of Needs differently. This means that there will be cases where two children have very similar needs but one has a Record of Needs while the other does not. There was a general view, therefore, that Records of Needs are not a good indicator of priority.

83. SLT managers also gave examples of education service developments which have resulted in children with similar needs receiving different levels of therapy even within one area. This was seen to raise issues about clinical governance and potential clashes with statutory imperatives.

84. A further concern was raised by SLT managers in relation to the link between funding and the Records of Needs system. Increasingly therapists are prioritising early and preventative work with younger children yet there are few children with a Records of Needs under age 5 and only a handful with Records of Needs at age 2.

85. Purchasers explained that authorities are reluctant to consider a child for a RON as early as age 2 as a period of development may occur at such an early age and the educational needs of the child may change significantly. However, they suggested that this should not mean that a child's need goes unmet. They also give a high priority to early and preventative work with younger children. Purchasers expressed the view that Records of Needs should not be seen as a passport to services as agencies must meet the needs of children whether recorded or not. In practice, is seems that the requirement to target education funding towards children with Records of Needs or being considered for a Record of Needs is interpreted differently from authority to authority.

Contracts and monitoring arrangements

86. Several NHS managers suggested that the contractual nature of the relationship between health and education has a negative impact on their ability to work in partnership. They suggested that too much of the dialogue between the two agencies is focused on funding and the contract itself and that this does not necessarily lead to mutual understanding. A further disadvantage of the contracts with Education identified by NHS managers was that Heads of Therapy have to negotiate with both Trusts and Education for any developments.

87. Purchasers also described some problems with the contracts. Because they find it difficult to differentiate posts that are additional to those funded by the NHS Trusts this in turn has made monitoring of the education funded service difficult. Education department purchasers in one area also said that they find it difficult to identify one senior manager with overall responsibility for dealing with problems that arise.

Lack of co-terminosity

88. Both NHS managers and Education purchasers described difficulties resulting from the lack of co-terminosity of NHS Trusts and Local Authorities. The main concern of SLT managers was that negotiations are time consuming. Purchasers said that they have particular problems when smaller Local Authorities are dealing with a large NHS Board area. They said that therapies tend to want to adopt a common approach across a whole NHS Board area meaning that the Local Authority has to fit in with this rather than develop a pattern of service that fits with the Local Authority.

The costing of therapy

89. NHS managers highlighted a lack of consistency in the way costs are calculated when drawing up contracts. They explained that local authority contracts often do not cover sick leave, maternity leave, study leave and costs such as clerical support or accommodation and said that some Education departments are only willing to pay for direct contact time. This has led to some employees in the same SLT service having different terms and conditions and different holidays in term time dependent on the contract under which their post is covered.

90. Some NHS managers suggested that there should be a national format for calculating costs and negotiating details of the contract and that the Scottish Executive should have a role in giving guidance about this and the subsequent auditing of any system introduced. The lack of clear ring-fencing of monies was raised as an issue by both managers and purchasers.

The link between funding arrangements and accountability

91. Both NHS managers and Education department purchasers were concerned that there are some ambiguities about responsibility and accountability for SLT for children with special educational needs and that this is key to any discussion about funding arrangements.

92. NHS managers thought that there was a potential conflict between being accountable for the deployment of the staffing resource but lacking control over finances that come from Education departments. They suggested that the present funding mechanism causes confusion about accountability and can allow for complaints to be by-passed by education.

93. Equally, Education purchasers expressed concern that they have a legal responsibility towards children with special educational needs but have to rely on good will and negotiation with health colleagues to ensure that this responsibility is met. Purchasers suggested that the NHS either has to have equal legal accountability with Education departments or that any legislation directed at education needs to be backed up with clear guidance to health services.

Alternative funding arrangements

94. Managers and purchasers were asked to consider alternative models of funding therapy. Many NHS managers were very interested in the idea of aligned budgets for health and education. However, they said that this would raise many questions about how it would work in practice, for example, who would be the employer and would therapists lose Whitley Council pay and conditions. It was felt that there are lessons to be drawn from the Joint Future initiative and that the same protective policy framework is needed if aligned budgets are to be implemented in children's services.

95. There was a consensus among purchasers that there has been too much 'tinkering at the edges' of services. They explained that obtaining small amounts of additional time-limited grant funding takes up a disproportionate amount of energy. There was not a consensus, however, about the best way to fund therapy for children with special educational needs.

96. One group of purchasers suggested that there needs to be a more long-term strategic approach to funding and joint resourcing and a policy framework to support joint work. They would like to see a Framework for Children's Services developed in which health, education and social work all have shared accountability. They felt that 'For Scotland's Children' ⁷ promotes working together and Children's Service Plans are a vehicle for joint planning but there also needs to be joint accountability along with joint resourcing of services. They said that if it is not possible to have joint accountability then accountability should be with one agency.

97. The second group of purchasers were less optimistic about joint resourcing expecting it to be 'a long and painful a process'. One purchaser would like to purchase SLT from a private agency or directly employ therapists. Others thought that it would be difficult to recruit therapists. They said that recruitment is difficult enough for the NHS even though they have a support structure, training and pay structure in place.

Views of NHS managers about the funding for therapy through mechanisms other than Education contracts

Inadequacy of current funding levels

98. The major issue raised by managers from all three professional groups when asked to comment on funding was the inadequacy of the central funding currently available. Several managers highlighted the problem, as they saw it, of static health resources trying to meet increasing demand from education. They called for permanent funding for core work and service developments.

Problems associated with time-limited funding

99. While managers welcomed new initiatives such as Sure Start, many expressed considerable concern about this mechanism of funding service developments. First, the short-term nature of the funding was a concern. It was stated that this causes extra pressure on a service and difficulties for managers. For example, it requires that people are appointed on short-term contracts but it is difficult to recruit to these posts.

100. Secondly, the process of applying for grants was a concern. Some mentioned that it is very time consuming to prepare a bid for funding with no guarantee of a successful outcome. A small number of managers from all three professional groups reported that paediatric therapy is not necessarily seen as a high priority within a Local Health Care Co-operative or NHS Trust. This makes it difficult to get grant funding bids accepted at this level and also means that therapy for children is competing with therapy for adults for resources. One manager stated that her Trust was reticent about embarking on funding which is non-recurring. There was a call for grant funding to be simplified and for information to be made more accessible to therapy managers.

Alternative funding arrangements

101. There was a call for agencies to have shared financial responsibility to meet the needs of disabled children. Some NHS managers from all three professional groups said they would welcome increased joint funding of services. This was described variously as 'pooled budgets', 'matched funding' and 'joint funding'. NHS managers felt that Social Work Departments should
be included as well as health and education in this joint approach to managing and funding children's therapy.

102. However, some concerns were expressed about therapists' ability to make their own professional judgements if Education departments are given a budget to purchase OT and PT or if joint resourcing arrangements are put in place.

103. Concern was also expressed that much of the current funding designated for interagency work (such as Sure Start) is, in fact, controlled by Local Authorities. These concerns, whether real or perceived, highlight the need for jointly agreed objectives and outcomes.

The importance of integrated therapy provision

104. Finally, managers stressed the importance of having integration of all therapy provision for children in localities. In some areas the current structure of therapy service was seen as restrictive. For example, where therapists are located within several Local Health Care Co-operatives this was seen to reduce flexibility in service provision. There were fears that services may become more fragmented if funded through Education departments.

105. It is important for different therapies to link together (be integrated) as well as to maintain good links (good integration) with other services/professionals. For this to be achieved, flexibility is required. For example, for geographical reasons, in remote and rural areas there may not be sufficient staff numbers to have a WTE in each locality. There may, therefore, be merit in having a more centralised therapy service to respond to fluctuating demand at local level. However, in more populated areas, there is much to be gained from deployment of staff in multidisciplinary teams at locality level, whilst retaining professional links and governance in a virtual way.

MANAGEMENT AND ORGANISATIONAL ISSUES

Joint working between health and education

106. Many Speech and Language Therapy managers were very positive about the relationship between their service and Education Departments, describing the relationship as a 'partnership'. They reported increased joint working at both a practice level and a strategic level, a better understanding of respective roles and better communication resulting from education funding.

107. However, others gave examples of collaboration working less well. For example, they felt that some education service developments had been implemented without the implications for the Speech and Language Therapy service being fully appreciated. They suggested that health priorities and philosophies are not always the same as those in education and called for more joint decision making and planning.

108. Education purchasers' views about joint working were mixed. In one area purchasers from Education departments reported that there is a will on the ground to work together. However, agencies' ability to provide a holistic service can be hindered by disputes over resources and domains of responsibility. The example was given of a bench used by a PT in a school to undertake a PT programme. There was some ambiguity about whether this was an item of health equipment or education equipment.

109. In the second area there were a number of tensions between Education Departments and some Speech and Language Therapy provision. Purchasers believed that good co-operation often relies on individual personalities and there was also the perception that therapists sometimes get involved inappropriately in education matters. However, in the same area, there was an example of good co-operation with the head of service working at a strategic level with Education colleagues to redesign services for children.

110. Purchasers in both areas pointed out that just as education developments can impact heavily on health, health initiatives and medical advances can impact on education. For example, more children with complex needs are now living longer and are no longer living in hospital settings. As a result schools are increasingly meeting the needs of these children. The purchasers welcome these medical advances but also point out that these place greater demand on education. In addition, the more children being diagnosed with ASD in the health sector, the more the education sector has to respond to this newly identified need.

111. Both NHS managers and Education purchasers want to see more co-operation between agencies. At the same time NHS therapists placed great emphasis on the importance of being able to exercise professional autonomy and clinical judgement as health professionals.
Some concern was expressed that this could be threatened if therapists were part of the education system.

Joint working between Local Authority and NHS OTs

112. The review was unable to look in detail at issues relating to the roles of Local Authority and NHS OTs. However, there are some issues described below which were highlighted.

113. Local Authority OTs described a number of arrangements that were in place to ensure good joint working and effective communication with NHS colleagues. These included formal and informal meetings, joint home or school visits, joint assessments, joint working on adaptations and joint reviews of individual children and their needs. These were said to reduce the possibility of duplication of work with children.

114. However, there still appears to be considerable scope for overlap of roles and it was not always clear where the responsibility lies for providing certain aspects of an OT service to children. Therapists drew attention to the confusion that can exist. Nine authorities gave examples of services provided to children in schools. These were mainly in relation to equipment and adaptations. However, some examples given suggested that a wider rehabilitation role was being undertaken. There is a danger that there will be a duplication of effort in areas where there are both Local Authority and NHS OTs and the role demarcation is not clearly defined.

Equipment and adaptation provision

115. The assessment, provision, funding and maintenance of equipment and adaptations for disabled children are the responsibility of several agencies. Health are responsible for assessing for and providing health equipment. Local Authority social work services are responsible for assessing and ensuring the provision of equipment and (temporary) adaptations for daily living - for children at home. Provision of permanent adaptations is organised according to tenure of the property. Education departments have a responsibility to provide any aids, equipment or adaptations needed by a child to access the curriculum. Assessments for equipment and adaptations needed by children in schools are typically undertaken by an NHS or Local Authority therapist and recommendations are made to the Education department who then purchase the equipment.

116. In a small number of areas some NHS therapists have access to a Local Authority equipment store or there is a joint equipment service in operation. An even smaller number have a joint funding protocol or pooled budget arrangements in place. Other areas are in the process of developing joint arrangements as part of the implementation of 'Community Care: A Joint Future'. ²⁴ New regulations on pooled budgets came in on 1 January 2003. We heard of one area at least that is developing a joint health, education and social work equipment service with money from the Changing Children's Services Fund and others where discussions are taking place. Where these joint arrangements are in place, they were welcomed by therapists and Education colleagues. In some areas, Speech and Language Therapists have access to a central resource which offers assessment and advice in relation to communication technology as well as systems for ordering, monitoring and repairing items. These resources were valued by those who can access them.

117. Both the surveys and the interviews undertaken highlighted two key concerns in relation to equipment for children with special educational needs.

118. First, there appears to be some ambiguities about the responsibilities of each agency in relation to various aspects of the process such as the assessment, funding, provision, maintenance, cleaning, storage and reissuing of equipment. In some instances it appears that agreements about, for example, responsibilities for funding equipment, have been in place in the past but have now become obsolete. In other cases these agreements have never existed. There were also some areas of equipment provision, such as advice regarding, and supply of, car seats, that were described as 'black holes' i.e. no-one appears to take responsibility. There was some evidence that agencies are not always able to meet their responsibilities in relation to equipment provision due to budget constraints. There appears to be particular issues around the funding of Alternative and Augmentative Communication aids and items of equipment used by children in respite or 'share the care' arrangements. It was also the perception of some Education departments and Social Work departments that some NHS OTs have recommended equipment which is a higher specification or newer model and therefore more expensive than is necessary to meet the
child's need.

119. Secondly, the systems to deal with equipment are often inadequate, inefficient and uncoordinated. NHS therapists often reported delays in provision by Social Work departments or Education departments following assessment. Also, there was some evidence of wastage where equipment, which could potentially be reused, is lost or even discarded despite only needing to be cleaned or to receive a low level of maintenance, due to poor storage, stock management and cleaning facilities. One group of purchasers said that this has become more difficult since disaggregation. They also explained that are some legal issues about the recycling of equipment.

120. Some areas have access officers based in Education departments who deal specifically with equipment and adaptation issues. These posts were seen as valuable by Education and NHS staff members.

Shared accountability

121. As stated earlier the question of accountability was seen as a key issue both in relation to contracts between Education departments and SLT provision and in relation to joint working more generally. Education departments felt that accountability needs to be with either one agency or to be joint. Some Education departments would like to see a Framework for Children's Services developed in which health, education and social work all have shared accountability.

Linking resource allocation and clinical effectiveness

122. Purchasers expressed uncertainty about the assessment criteria used by therapists when making recommendations about the allocation of Education resources. Their perception is that decisions about particular pieces of equipment or interventions can appear to be based on individual subjective opinion or unduly influenced by parental pressure.

123. Purchasers were also concerned that it can be confusing for parents when different services in neighbouring localities adopt different 'methodologies' such as a mainly 'hands-on' approach or a mainly 'hands-off' approach. They explained that parents tend to see a hands-off approach as less valid and need to be convinced of its value. Purchasers called for therapists to be more explicit about the available clinical evidence when making recommendations or adopting certain approaches in order to foster good relationships with parents and enable Local Authorities to demonstrate that best value is being secured.

The impact of inclusive education and new models of service delivery

124. NHS managers are aware of the increased pace of change towards inclusive education for disabled children. The move towards 'mainstreaming' has already affected roles and service delivery models. Managers expressed the view that the policy has put increased pressure on therapy provision, as the placement of 'special needs children' in a number of mainstream schools, sometimes spread over a wide geographical area and without any increase in therapy provision has resulted in services being stretched ever thinner. They have major concerns regarding the ability of the service to deliver an equitable service within an inclusive schooling system.

125. Purchasers suggested that there should be joint training around inclusion. They were concerned that some people in both health and education "still think that special is best". They thought that Higher Education institutions which train therapists and teachers should work together on such a training programme.

126. It was not within the remit of this review to evaluate service models. However, it is clear that the model of service delivery has an impact on the way demand is managed. Speech and Language Therapists reported that they provide indirect work and direct one-to-one interventions equally. This does not appear to be the case for Occupational Therapy and Physiotherapy who provide mainly direct interventions in the areas we visited. The most striking example of a new model of working was in Lomond and Argyll's Speech and Language Therapy service for adults with learning disabilities where they use an approach called Total Communication. This service model is delivered almost entirely through indirect training and support allowing the service to reach a large number of people. This approach is described further in Part 6.

Facilities in schools

127. Both NHS managers and Education department purchasers highlighted the problem of shortages of suitable accommodation for therapy provision in health centres and schools. Sometimes therapists use the school medical room, the gym or any other room that is free. Purchasers admitted that therapists sometimes end up with the worst room in the school due to a shortage of space and a lack of resources to enable schools to extend. There did not appear to be clarity about what was acceptable or desirable. Purchasers suggested that there should be clear guidance given to Local Authorities about the facilities that therapists should expect in school - size, design, temperature, and quality standards.

SUMMARY AND CONCLUSIONS

SUPPLY AND DEMAND ISSUES

Analysis of workforce factors

128. The data collected through the surveys confirm the Riddell Committee's concern that there are shortages of NHS therapists working with children and unacceptable waiting times for some children.

129. It is difficult to reliably quantify supply and demand due to the varied interpretations of terms such as 'caseload' and different approaches to managing referrals. However, the investigations have allowed a deeper understanding of the multiple factors affecting supply and demand to be developed. Factors include too few experienced therapists, recruitment difficulties in rural areas and growing numbers of referrals. Overall the picture is of resources that are stretched and are put under greater pressure due to high rates of maternity leave and sick leave.

130. It is important to note the potential impact of analysis of roles within and between professions not covered by this report.

Supply factors currently affecting the workforce

131. There are a number of key factors influencing the supply of NHS therapists. First, although actual numbers of vacant posts are low, there are high vacancy rates in children's therapy and many of these persist for three months or more. This is particularly an issue in remote and rural areas.

132. Secondly, there is currently too small a pool of therapists to draw upon to fill senior l,
senior ll and band 2 posts. In addition, there are too few opportunities for therapists to develop paediatric experience. Problems highlighted include too few basic grade paediatric posts; a lack of rotational posts; limited numbers of senior ll training posts for therapists in specialities such as paediatrics and neurology; too few paediatric fieldwork education placements for student therapists and too little continuing professional development for therapists wishing to move between specialities. All of the above were seen as useful ways to support recruitment and retention.

133. Thirdly, there is evidence that skill mix is being affected by the pressure to meet demand. As well as very few Basic Grade or grade 1 posts established in OT, PT and SLT, there are also fewer clinical support worker posts established in OT and PT than in other clinical areas. The long-term sustainability of the workforce relies on having a good career structure for therapists and clinical support workers to move through.

134. Fourthly, inadequate administrative support for therapists and IT infrastructures also appear to be having a negative impact on ability to meet demand for therapy. Data were not specifically collected on this activity but there is evidence from managers and steering group advisors that time spent may be significant, perhaps as high as 30%.

135. Also, temporary absences such as maternity leave and sick leave are not well managed at present and posts may not be covered. Managers would like to have ring-fenced staffing budgets, contingency funds to cover maternity and sick leave, supernumerary staff to cover fluctuations in staffing, and automatic or emergency approval of funding to cover maternity leave from the first day of a maternity leave absence rather than after 18 weeks.

136. Finally, the introduction of family-friendly policies is having a positive influence on recruitment and retention. However, this creates new challenges such as maintaining continuity within the service and good communication when so many employees work part time.

137. In addition, some Local Authorities are experiencing difficulties with recruitment and retention of experienced OTs and part-time employees and are finding that temporary posts are also difficult to fill.

138. Both NHS managers and Local Authorities described difficulties providing good support and supervision to therapists working in remote and rural areas.

Current demands on services in which therapists work

139. Some children are waiting for long periods to receive therapy from the NHS. The longest waiting time in several areas is more than six months and it can be up to two years in some cases.

140. Children in rural areas appear to be experiencing longer delays. There is also evidence that children who speak minority languages are waiting longer than children from English-speaking families to receive an effective SLT service, because of a lack of bilingual therapy.

141. There were differences evident in the way that demand is managed by NHS services. Some NHS services operate two waiting lists, one for assessment and one for treatment. There can be potential problems if a child waits too long for treatment as they will need to be reassessed. Some services have a formal system in place such as 'SMART' goals or 'Care Aims' to review progress and make decisions about discharging children. Others do not.

142. Where there are limited resources the choice may be between providing minimal interventions to as many children as possible or in-depth interventions to those children considered to be in greatest need. There appears to be inequities of service both within and between NHS Board areas.

143. Some children are also waiting for long periods to see a Local Authority OT, particularly in rural areas.

Addressing workforce issues effectively

144.Our National Health³⁰ states the government's expectation that the numbers of Allied Health Professionals will rise. Long waiting lists and increased demand from children with ASD and children with complex health needs, as identified in this review, would indicate that children's services require an increase in numbers of therapists. Because of the gaps in data it is not possible to come to any firm conclusions about the absolute numbers of therapists needed to meet any shortfall.

145. Just as the factors affecting supply and demand are multiple, so the strategies needed to tackle the problems will be multiple. Increasing posts alone will not necessarily ease pressure. A long-term strategy for workforce planning based on a comprehensive analysis of multiple factors is needed.

146. The investigation has highlighted gaps in information that exist in relation to supply, demand and outcomes of interventions and a need to develop more sophisticated models to examine the relationship between supply, demand and outcomes.

147. For example, demand is typically measured in terms of numbers of referrals, waiting lists and current cases. However, our investigations have shown that currently these terms are interpreted and measured in different ways by different services. In addition, it is clear that these measures give only a partial picture of demand.

148. Ritchie et al.³¹ suggest that an analysis of supply and demand alone is problematic. They point out that any demands made on a service are likely to be influenced by existing service models and patterns of delivery. Demands, therefore, should be differentiated from needs. Instead they suggest a model which incorporates not only supply and demand but also need. They make a distinction between 'expressed need', 'normative need' and 'felt need'. 'Expressed need' is analogous with demand, 'normative need' is determined by experts and 'felt need' is influenced by an individual's expectations and experiences.

Source: Ritchie et al. 1996 ³¹

149. The task of related processes such as population needs assessment, service design and workforce planning is, therefore, to ensure that any divergence of supply, demand and need is minimised. The report from the Scottish Integrated Workforce Planning Group ³² also stressed the need to look at workforce issues alongside models of change, models of effective practice and service delivery.

150. In the case of paediatric therapy, workforce planning must link intimately with the current agenda of Inclusive Education. Inclusive Education is already having an impact and will continue to have an impact on the way children's 'needs' are conceptualised, desirable outcomes are defined, the competencies required by therapists to meet children's needs are understood, new models of service provision are developed and new approaches to management and supervision are initiated. The Royal College of SLTs have identified competencies needed to work with certain client groups; other professions have not.

151. Both Building on Success³³ and Working for Health³⁴ identify the development of good information systems as a priority for good workforce planning. In order to have a positive impact, any new information systems developed need to contribute to a wider process of population needs assessment and service (re)design.

152. There will also be a need to pay particular attention to remote and rural issues. There is evidence that children are waiting longer for a service in some remote and rural areas than children in urban settings. There are higher vacancy rates in these areas and it is difficult to attract therapists to move into the area and peer support and supervision are more difficult to arrange.

153. Finally, the views of children and families should be central to any developments and efforts should be made to involve families in a meaningful way.

Maintaining and increasing the pool of experienced therapists and clinical support workers

154. The key workforce issue which must be addressed is the need to maintain and increase the pool of therapists who are suitably trained and experienced to meet the needs of children in an inclusive school system. Retention of experienced therapists relies on a well-planned and structured programme of Continuing Professional Development to maintain the currency of therapists' skills as services develop.

155. A number of strategies could be used to increase the supply of experienced therapists, some requiring longer-term planning than others. Options include:

a) increasing the numbers of OTs, PTs and SLTs that are trained

b) establishing more basic grade rotational posts or senior ll training posts in paediatric services and putting in place a training programme co-ordinated by an external organisation

c) providing intensive training courses for new graduates and therapists working in other clinical areas to enable them to work with children

d) providing a structured programme of training for clinical support workers and increasing opportunities for access onto courses leading to state registration

e) investing in return to work initiatives

f) recruiting therapists from outside the UK.

a) Increasing the numbers of OTs, PTs and SLTs that are trained

156. Four Higher Education Institutions in Scotland provide pre-registration education and training for those wishing to train as Speech and Language Therapists, Occupational Therapists and Physiotherapists. Institutions offer three-year ordinary degree and four-year honours courses to undergraduates and some offer two-year post-graduate courses. All lead to eligibility for state registration.

157. The Scottish Executive and Scottish Higher Education Council (SHEFC) have increased funding for two years running to increase the number of places for students on under-graduate courses, although there is no guarantee that such students will work with children.

158. The two-year post-graduate courses offer the quickest route to increasing numbers of therapists. However, the number of students taking up places on these courses is lower than the number of available places as each student has to fund the course him/herself. Because students have already undertaken at least three years education at under-graduate level they are not entitled to further financial support.

159. As well as increasing the number of therapists trained, it will be important that students have positive experiences of working in the field of paediatrics through fieldwork education to encourage them to choose this specialism. At present, one of the factors limiting student placements is the availability of the clinical supervisor allowance. This is covered under Whitley Council pay and conditions and is paid by NHS Trusts to therapists who supervise students for a minimum number of weeks in the year. Students may be refused a placement because there is no money available from the Trust to cover this allowance rather than the supervisor's ability to offer time and expertise.

160. Students should also be given the opportunity to experience working in a remote or rural setting through fieldwork education to challenge some of the preconceptions about work in rural areas. There may be some barriers to rural placements such as the high demand for services faced by rural practitioners, the problem of transport and travel expenses and the issue of placement type, that is, day placements versus block placements.

161. Finally, OT, PT and SLT education is generic and cannot cover every specialist area in depth. However, a few specific paediatric modules are offered during pre-registration education. It will be important that these modules are developed as inclusive education progresses in order to offer students an insight into the changing role of OTs, PTs or SLTs in children's services.

b) Establishing more basic grade rotational posts or senior ll training posts in paediatric services and putting in place a training programme co-ordinated by an external organisation

162. There appears to be differing views regarding the ability of new graduates to work in paediatric services, particularly in community services and mainstream schools. There appears to be two related concerns; first, the new graduates' lack of skills or experience in this environment and secondly, the service's lack of ability to deliver the right level of support, training and supervision when experiencing high demand for therapy. There is a need to find new ways to support and train new graduates. It may be helpful for educational institutions to work in partnership with practitioners to develop support and training mechanisms for new graduates working in paediatric services. The input of practitioners to any programme of training or support would be essential as would continuing education back in the clinical field. However, the educational institution could take on the role of co-ordinating at a regional or national level practitioner input, mentorship or peer support arrangements, web-based learning and specialist courses.

c) Providing intensive training courses for new graduates and therapists working in other clinical areas to enable them to work with children

163. The same process of education and support described above could be used with therapists wishing to move from one specialism to another.

d) Providing a structured programme of training for clinical support workers and increasing opportunities for access onto courses leading to state registration

164. It is important to provide robust support and training to clinical support workers. The current training available for clinical support workers working in each profession is variable. A Higher National Certificate in Occupational Therapy Support is run in some areas. The HNC provides a generic training but allows participants to tailor projects or assignments to the clinical specialism in which they are based. There is no equivalent course for Speech and Language Therapy or Physiotherapy clinical support workers.

165. Clinical support workers may undertake Scottish Vocational Qualifications (SVQs), which have a generic focus. In at least one area, a paediatric SVQ module is being developed with support from the Changing Children's Services Fund.

166. The HNC in OT Support is usually taken up by Occupational Therapy clinical support workers who are already employed rather than those who are looking for future employment as an OT or OT clinical support worker. The qualification allows accelerated entry onto the Occupational Therapy degree course. There would be value in developing an equivalent course to the HNC in OT Support for Speech and Language Therapy or Physiotherapy clinical support workers. There may also be value in providing a similar course for people employed in different fields who want to change career. The development of specific paediatric SVQ modules is also to be welcomed ³⁵.

e) Investing in return-to-work initiatives

167. There are now examples of training and support programmes available for health professionals wishing to return to an NHS post after a career break. Building on Success³³ recommended that the Scottish Executive develops these further.

f) Recruiting therapists from outside the UK

168. There has been little research into the scope for international recruitment of AHPs. However, evidence presented to the Review Body for Nursing Staff, Midwives and Professions Allied to Medicine ³⁶ suggested that approximately one-third of physiotherapists joining the Health Professional Council register each year were from overseas.

FUNDING ISSUES

Sources of funding

169. Most NHS therapy posts are funded from the mainstream health budget. The exception is SLT which receives a significant amount of funding from Education departments. There is not the same mechanism for the purchase of OT and PT for children by Education departments.

170. The proportion of funding for SLT coming from Education departments is relatively high in some areas such as Shetland at 91% and Glasgow at 60%. This funding is intended to provide an enhanced service targeted at children with Records of Needs or being considered for a Record of Needs. In areas where the proportion of education funding is high and the proportion of health funding is comparatively low, questions are raised about the ability of the service to meet the needs of non-recorded children.

171. The purchasing of therapy by grant-aided schools also has the potential to create inequities over and above those that already exist.

172. The majority of Local Authority OT posts in the areas for which we have data are funded from the Authority's mainstream budget. There has been little uptake of time-limited grant funding such as Sure Start, New Community Schools and Innovations grants by NHS or LA therapists.

173. There appears to be a number of potential barriers to further take-up by NHS therapy. First, NHS therapists' perception was that therapy are considered a low priority by NHS Trusts when applications are being prepared and so are not included in project designs. Also the NHS managers themselves consider the preparation of applications for time-limited funding to require disproportionate amounts of effort and time to secure relatively small amounts of additional resources. Finally, the grants tend to lead to the creation of temporary posts which they perceive as unattractive.

174. These grants could offer good opportunities to therapy to work collaboratively with education and other agencies. Although these are time-limited funds, they lend themselves well to supporting the sort of innovation that will be needed as inclusive education progresses. Both NHS managers and Education purchasers called for less piecemeal development and more strategic funding structures.

Pay and conditions

175. There is a growing pay differential between NHS SLTs and other NHS Allied Health Professionals, and between NHS therapists and Local Authority personnel. Education contracts are also leading to anomalies in pay and conditions. These could potentially impact on recruitment to certain professions and certain agencies and should be addressed. This will become an even more pressing issue as the Joint Future agenda progresses, as there will be more joint health and social work services creating potential for therapists to be based together but on very different terms and conditions.

Improving funding arrangements

176. NHS Therapists from each of the three professions expressed concerns about the ability to meet increasing demand without additional resources.

177. The additional funding received by SLT through Education departments was welcomed by managers. The main benefits of the funding identified by SLT managers have been increased staffing and a greater dialogue between NHS therapists and Education services.

178. However, the review has identified a number of difficulties relating to the funding mechanism that are similar to those outlines in a paper produced in 1999 by Speech and Language Therapists in Scotland. ³⁷ These include the 'unhypothecated' nature of the funding, the perceived lack of an equitable distribution of the money across Scotland, and the protracted amount of time and energy that is spent on negotiating contracts.

179. There is also evidence that SLT is being eroded on a number of fronts. First, health developments are not keeping pace with education developments. Secondly, Local Authority cost-of-living rises are not reaching actual cost increases. Finally, the additional costs resulting from the SLTs' realignment exercise are being met, in some cases through service cuts, despite this being discouraged by the Scottish Executive.

180. The link between the funding and the Record of Needs system was seen as particularly problematic. There was agreement across agencies that these records are not a good indicator of degree or urgency of need. Agencies also saw early intervention and preventative work with younger children as a priority that falls outside the Record of Needs system.

181. Another key issue was the lack of transparency about who is paying for what. Purchasers have experienced difficulty differentiating Health and Education funded posts and this has caused difficulties when monitoring contracts.

182. It is clear that the current mechanism of funding SLT through education contracts is problematic and that the mechanism should not be replicated for OT and PT in its current form. However, there is not a clear consensus about the most appropriate mechanism for the funding of therapy for children with Special Educational Needs in the future. Some purchasers and NHS managers favour joint resourcing while others would like to see a single agency taking responsibility for therapy for children with Special Educational Needs.

MANAGEMENT AND ORGANISATION ISSUES

Joint working

183. The work of Education, Social Work and Health is very closely related. Developments introduced by one agency have a direct impact on the other agencies' work. At present there is some ambiguity about the responsibilities of each agency and this can lead to conflict and disputes about resource allocation. Close co-operation and good communication at all levels is crucial if agencies' vision of an holistic service is to be achieved.

184. There was not a consensus about the best way to achieve a joined-up approach, however, there was agreement that clear lines of accountability are crucial. Some respondents were in favour of joint resourcing and management arrangements but also stressed that these would need to be supported by a robust policy framework.

185. It is hoped that any current duplication of effort in areas, where there are both Local Authority and NHS OTs and the role demarcation is not clearly defined, will be resolved by joint resourcing.

Equipment and adaptation services

186. Equipment and adaptation services are fragmented with each agency having different responsibilities and different areas of expertise. Responsibilities are not always clear and the systems to support the service are either inadequate or in some cases non-existent. There appears to be a number of specific gaps that need to be investigated further and addressed such as the funding of Alternative and Augmentative Communication aids and equipment for children using respite or 'share the care' arrangements. The current division of responsibility for the purchasing, assessment and maintenance of equipment used by children in schools and home is unsatisfactory.

187. Agencies welcomed joint initiatives where they exist. Equipment and adaptation services is one area that was highlighted as a priority for action in 'Community Care: A Joint Future'. Joint equipment and adaptation services are currently being developed. A similar model would be equally applicable to children's equipment and adaptation services. Developments need to take account of the specific need of children and of the Education departments' role. From 1 April 2003, all Local Authorities will be required by the Accessibility Strategies Act to have in place
a strategy for making education more accessible for pupils with disabilities. National funding
has been made available to Local Authorities to help them prepare and implement their accessibility strategies.

Working within an inclusive education model

188. Any developments in the management, organisation and provision of therapy to disabled children need to be considered in the context of Inclusive Education. The increasing emphasis on mainstream education for disabled children will bring both opportunities and challenges to stakeholders. It will be important to maintain a dialogue between all agencies as well as parents and children as new models of working are developed to meet the needs of children in inclusive educational settings. There will be a requirement to develop shared understandings and expectations of therapy and its likely outcomes.

189. It appears, at present, that Education staff and parents are sometimes unclear about the basis on which clinical decisions are made by therapists. Education colleagues believe that greater explanation about the rationale for clinical decisions will reduce conflict and increase joint understanding between all parties.

190. There was also a call for more joint training initiatives aimed at therapists and education staff and specifically addressing the inclusive education agenda. Such joint training initiatives should be made easier with the introduction of the McCrone report ³⁸ which guarantees all teachers
35 hours in-service training per year. It will be important to include parents and, where appropriate, children in any joint training initiatives to ensure that they are able to take an active part in the development of inclusive education.

191. Finally, the need for a more strategic approach to the provision of facilities in schools to accommodate children's therapy needs has also been highlighted.

RECOMMENDATIONS

192. The working group proposes a number of recommendations relating to issues of strategic planning which take account of recent reports and current Scottish Executive initiatives in Education, Health and Social Services. These include For Scotland's Children; Building on Success: Future Directions for the Allied Health Professions in Scotland; and Community Care: A Joint Future.

193. Other recommendations are grouped within the terms of the remit for the review under supply and demand, management and organisation and funding. Others are listed under workforce or other issues.

Strategic Planning

a) The Scottish Executive should encourage providers to develop new models of NHS therapy provision in non-traditional and inclusive settings, such as mainstream schools and nurseries and other community settings; and multi-agency training initiatives to support the delivery of therapy to children in inclusive educational settings. [Part 3, paras 6-10; Part 5, paras 124-126; 188-190]

b) Local authorities and NHSScotland should develop integrated approaches to the provision of therapy and other related interventions for children. These approaches should be planned and resourced within the statutory framework of local planning for children's services. Inter-agency Children's Services Plans should describe assessed levels of need and the provision made to meet these. [Part 3, paras 14-15; Part 5, paras 106-111]

c) NHS and Local Authorities should apply lessons learned from implementation of the Joint Future agenda in community care services, to their implementation of For Scotland's Children, the Executive's initiative on better integrated services for children. [Part 3, paras 14-15]

d) The Scottish Executive Health Department, NHS Boards and Local Authorities should ensure that the national, regional and local structures established through Working for Health involve AHP leaders and that a systematic approach to workforce analysis and development is adopted for NHS paediatric therapy. This should be an integrated approach involving key stakeholders, e.g. professional bodies, HEIs and NES, and LA partners. [Part 5, paras 144-153]

Supply and Demand

e) NHS Boards and Local Authorities should review the structure and skill mix of therapy staff in services to children, to ensure effective and efficient use of resources, ability to meet demand and the provision of training opportunities for junior grades of staff and assistants. [Part 5, paras 22-24;133]

f) The Scottish Executive, the Scottish Higher Education Funding Council, NHS Boards and Local Authorities should together take steps to expand the pool of suitably experienced and skilled therapists and clinical support workers. They should take into account opportunities to develop alternative routes into state registration in partnership with the Health Professional Council (HPC), universities, NHS Education for Scotland, Scottish Qualifications Authority and professional bodies. [Part 5, paras 26-29;132; 154-155]

g) NHS Boards should progress initiatives to tackle recruitment, retention, training, supervision and support issues in remote and rural areas through the Remote and Rural Areas Resource Initiative (RARARI) in NHS Scotland. [Part 5, paras 30; 131; 138]

h) NHS Boards should take steps to minmise the length of time that children have to wait for therapy required to support their educational needs. [Part 5, paras 55-57; 139-143]

Management and Organisation

i) NHS Boards, Local Authorities and other employers of AHPs, in determining their therapy staffing complements for children's services, should take into account the impact of planned leave, including projected maternity leave, and changing workforce patterns, so that there is continuity and comprehensiveness of service as outlined in Building on Success - Future Directions for the Allied Health Professions in Scotland. In addition, they should use Partnership Implementation Network guidelines to develop and implement flexible employment policies to support the recruitment and retention of staff. [Part 5, paras 8-24; 31-37; 135-136]

j) NHS Boards through AHP leaders should audit the time spent by therapists on non-clinical tasks, such as routine administration, and seek to maximise AHP time on direct service delivery. [Part 5, paras 25; 134]

k) NHS Boards should fully utilise the enabling agreement and other mechanisms which exist to recognise and reward clinical expertise in order to promote job retention in paediatric services. These include developing opportunities for new ways of working and improving clinical care such as 'extended scope practitioners', clinical specialist or AHP consultant posts. [Part 5, paras 37-40; 154-168]

l) NHS Boards and AHP leaders from each therapy profession should ensure that each therapy profession has a clear rationale for caseload management decisions which is developed in consultation with key stakeholders such as parents, education colleagues and where appropriate children. [Part 5, paras 60-68]

m) AHP employers and leaders should support the development of multidisciplinary and multi-agency networks to underpin practice development. These should review and share clinical effectiveness information developed by each profession in partnership with families using services. [Part 5, paras 188-190]

Funding

n) Allocation of funding for Speech and Language Therapy to education authorities for provision to pupils with Records of Needs should be integrated with funding for SLT to other children. Provision of therapy should be made according to clinical need and be outcome-focused rather than led by diagnosis, label or administrative category. [Part 5, paras 82-85; 176-182]

o) The Scottish Executive should, with Local Authorities and NHSScotland, develop joint resourcing and management for children's services, including the therapy professions' contribution. [Part 5, paras 94-105]

Workforce

p) Competencies required to deliver and manage a high quality children's service should be established by OT and PT leaders in line with similar work in SALT. This should be undertaken in partnership with professional and regulatory bodies, and HEIs and used to inform the work of NES in developing education and training and continuing professional development. [Part 5, para 150]

q) NHS Boards and Local Authorities should create opportunities for students and new graduates to gain experience of working with children. In the NHS they should consider arrangements for the payment of clinical supervision allowances, within the timeframe for the implementation of the UK Agenda for Change initiative. [Part 5, para 159]

Other Issues

r) NHS Boards, Local Authorities and AHP leaders should develop strategies for involving children, young people and their families in service evaluation and development in line with the Involving People agenda, ³⁹ [Part 5, para 153].

s) NHSScotland commissioners with NHS Boards and SLT leaders should review the current level of bilingual SLT available to families from minority ethnic communities in their area and should take steps to address service gaps. [Part 5, para 58; 140]

t) NHS Boards and Local Authorities should put in place strategic planning arrangements to ensure that effective and efficient joint systems and protocols are developed to meet the equipment and adaptation needs of disabled children. These arrangements should cover assessment, funding, provision, monitoring, maintenance and recycling of equipment. Developments should link with activities under 'A Joint Future' and Education Departments' 'Accessibility Strategies'. [Part 5, paras 186-187; 115-123]

u) As part of local implementation of Accessibility Strategies, education authorities, in consultation with NHS Boardss and Head Teachers, should agree appropriate accommodation and facilities for the provision of therapy in educational settings. [Part 5, paras 127; 191]

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