Women and Equalities Committee
Oral evidence: Unequal impact? Coronavirus, disability and access to services, HC 386
Wednesday 22 July 2020
Ordered by the House of Commons to be published on 22 July 2020.
Members present: Caroline Nokes (Chair); Sara Britcliffe; Elliot Colburn; Angela Crawley; Peter Gibson; Kim Johnson; Kate Osborne; Bell Ribeiro-Addy; Nicola Richards.
I: Professor Gillian Leng CBE, Chief Executive, National Institute for Health and Clinical Excellence (NICE); Kate Terroni, Chief Inspector of Adult Social Care, Care Quality Commission; Simon Williams, Director of Social Care Improvements, Local Government Association; Celia Ingham Clark MBE, Medical Director for Clinical Excellence, NHS England.
II: Ali Fiddy, Chief Executive, Independent Providers of Special Education Advice; Charlotte Ramsden, Vice President, Association of Directors of Children’s Services.
Witnesses: Professor Gillian Leng, Kate Terroni, Simon Williams and Celia Ingham Clark.
Chair: Good afternoon, and welcome to the Women and Equalities Select Committee, and the inquiry into the unequal impact of Covid and its impact on disabled people and access to services. I thank all witnesses for joining us.
We have had some technical problems, but I can now ask Committee members in turn to ask you questions. They will direct their questions to individual members of the panel. If any of you, at any time, wish to add additional information or contribute, please raise your hand and I will bring you in at the appropriate time.
Q37 Sara Britcliffe: Good afternoon. My first question is to Gill. Can you describe the background to NICE issuing potentially discriminatory guidelines on the use of the clinical frailty scale in making decisions about who should get critical care for Covid-19?
Professor Leng: The background to this goes back to early March, when we were all watching what was happening as the pandemic was starting to spread across Europe. We had conversations with NHS England, which commissions our clinical guidelines programme, about what NICE might contribute to support the wider system in relation to guideline development. As you know—well, you might not know—our normal guideline development process takes two years or so. Clearly, that was not going to be fast enough in the scenario that we were facing. Our conversations were around whether we could do guidelines rapidly and then what topics we might cover.
We decided that we ought to. We felt that we had a moral sense to support the system and that we would develop a very rapid process for developing guidelines. We were referred three topics initially, one of which was a guideline for how services will be delivered during the pandemic for critical care. That was the framing of one of those three guidelines. We very rapidly put together an interim process that allowed us to develop that guideline in just over a week—so much more quickly than we would normally develop the guideline.
However, we stuck to our principles of guideline development by involving experts and looking at the evidence, although there, it is fair to say, there was not a great deal of evidence because the Covid pandemic was new, but we looked at the evidence there was. We did an equalities impact assessment during the guideline process and we ran a targeted consultation. It had to be targeted in that quick timeframe.
Normally, our guideline consultation is six weeks; we ran the consultation in six hours. We got 178 comments in those six hours. We had 26 organisations that contributed. We had comments back from the NICU charity and intensive care charity, from the British Heart Foundation and from the Richmond Group of Charities. We heard from the lead for learning disabilities across the national directorate.
Despite doing it so quickly, we had a comprehensive set of comments and they were supporting the use of the clinical frailty scale. It was something already in use across the system at that point. We did not hear any concerns about it being discriminatory in relation to disability at that point. We had already picked up in our own quality impact assessment that there might be an issue around age. We had picked that up and we framed the use of the clinical frailty scale in the guideline as something that needed to be part of a holistic assessment for the patient. It should inform a conversation about risks and benefits, so a discussion between the clinician and the patient. It was absolutely not about saying, “Here is a score” and that is all you do. It was very much about a wider conversation.
That was what we did to get the guideline out in a week. Because we had not done some of the stages that we might normally do, we had absolutely committed at the outset to a rapid process of updating. It was a way of mitigating the risk of going quickly by saying, “We will pick up any feedback as it comes through and we will amend as required”.
We published that guideline on 21 March and made an amendment on 25 March, because we heard from stakeholders that there were concerns about the use of that scale in people who were having help with daily tasks but were otherwise healthy. They felt they might be unfairly being scored on that scale. We made an amendment, emphasising that it was part of a holistic assessment. We were absolutely explicit about not using the scale in younger people or people with stable long-term conditions, such as cerebral palsy, learning disabilities or autism.
Q38 Sara Britcliffe: Following up from that, has there been an internal review of how this came about?
Professor Leng: We have reviewed our approach to developing these rapid guidelines. That was the first of 21, so we have learned as we have gone along. We have just published an updated process for developing rapid guidelines for things like public health emergencies for the future. We will make sure that we have a wider consultation period in the future and that we engage with, as we are doing for guidelines still coming through, the NHS England equalities team, to make sure we are being really rigorous about picking up any potential risks of inequalities.
Q39 Sara Britcliffe: That leads me on, and you have mentioned some of the actions that have been taken, but has NICE learned lessons about taking disability equality into account when formulating guidelines about access to treatment?
Professor Leng: We have always taken it very seriously. Our guidelines are always accompanied by an equalities impact assessment as we go through. We publish those as the guidelines are published. We are now very sensitive, of course, in relation to Covid-19. As I say, we are liaising closely with the NHS England equalities team to make sure we do not miss any issues there might be.
Q40 Sara Britcliffe: My next question is to both Gill and Celia. What steps have been taken to ensure the revised guidelines on critical care for Covid-19 have been effectively communicated to critical care clinicians?
Professor Leng: That is a very important point. We have done an initial press briefing, widespread use of social media, promoting the guidelines on our website, with links from the NHS England website, and we developed a specific Covid-19 newsletter, which has reached over 40,000 people. I mentioned one amendment. We have made a couple of small, minor amendments too. When we have made amendments, we have been very clear on the website that those points have been amended, to highlight that there have been changes to the audiences.
Q41 Sara Britcliffe: On that, what other small, minor amendments were made?
Professor Leng: There was one minor amendment on 31 March, which was just a moving of text to emphasise the use of the scale, because of a concern that they felt it was not obvious enough that it was part of a holistic assessment. Then, towards the end of April, we had some feedback about concerns in relation to neurological conditions. We added an addendum to a sentence that said, “Involve relevant specialists if needed, such as for people with dementia”.
Celia Ingham Clark: The learning disability team in NHS England highlighted the amended NICE guidance in its messages to stakeholders shortly after the publication.
Q42 Sara Britcliffe: Again to you both, can you give an assurance that nobody with a learning disability, autism or a stable long-term disability will be disadvantaged in access to critical care during the pandemic?
Professor Leng: Our guideline is absolutely clear that there should not be any discrimination. There should always be a conversation between the clinician, the patient and the patient carers and family. It absolutely does not set out any discrimination as such. Of course, guidelines should always be used locally by clinicians. Sometimes, perhaps, they are used inappropriately, but the intention of the guideline is clear: that they should not be discriminatory.
Celia Ingham Clark: We have linked this in some of our messages to the system about the use of “do not attempt resuscitation” guidance. In particular, at the end of March, we prepared and published speciality guidance on how to manage people with learning disabilities during the coronavirus. That was very clear about the importance of avoiding inequitable management of such patients.
Q43 Chair: Can I pick up on something Gillian said and ask for some more clarity? You referred to guidelines for a public health emergency. Does that mean you drafted new guidelines or you updated existing guidelines? What is the robustness of your preparedness for future pandemics? What was your level of preparedness prior to Covid appearing in this country?
Professor Leng: To use rather an overused word, it was unprecedented for us to develop guidelines in this way. We have a well-used, internationally respected approach to developing guidelines that is predicated on a lot of stakeholder consultation, reviewing a large amount of evidence and getting feedback on draft documents. Over the course of a week, we developed an interim approach for developing rapid guidelines. We used that for the first 21 guidelines.
We have now reviewed that. There is a much more comprehensive guide now on our website for the approach we will take in the future. That has very much learned from what we did the first time round. I am absolutely sure, as the pandemic continues, that we will need to use this approach moving forward for updating the existing guidelines. Although we did them, they are being maintained. We are looking at masses more evidence as it comes through. It is an ongoing big task, so we are using the updated process.
Q44 Chair: Did you have previously, or do you have now, a clear definition of what constitutes a public health emergency?
Professor Leng: We have defined in this process now when it will apply. This rapid process applies when there is a need to have guidance developed very quickly because the need of the population, in essence, overrides the risks that we might be taking by doing the work more quickly than we otherwise would. We have defined in this process what we mean by an emergency situation. We did not have that at the very beginning. We just knew we had to work quickly and do this or there would not be the advice out for the system that was needed.
Chair: You have it now. You did not have it then.
Q45 Kim Johnson: Good afternoon. I have four questions, and they are all directed towards Simon and Kate on Care Act easement. Has either of your organisations collected data on the numbers and groups of disabled people who have been adversely affected by the Care Act easement triggered by eight local authorities? Are you aware of any organisations compiling this data? Is there enough transparency? How are we to know whether the eight councils that have triggered the easements have fully justified their decisions?
Kate Terroni: I am Kate Terroni, chief inspector of adult social care at the Care Quality Commission. Our role as the regulator is to regulate the quality of health and social care providers. We do not have a direct role in local authorities or commissioning. However, we have a job to talk about what the impact of these sorts of changes is on the population and those people who receive health and care.
When the Care Act easements came into force, we worked closely with the Local Government Association, ADASS—the directors of social services—the Department and, most critically, Think Local Act Personal. As you probably know, Think Local Act Personal is a national partnership organisation that does an excellent job at representing the voices of those people with care and support needs.
As for the role we specifically took within CQC, when local authorities turned on the easements—there were eight that did during that time, and it is worth noting that none of those is in place now—my senior heads of inspection had conversations with each of the eight directors of social services and ran through a kind of checklist, so we could be assured that there had been transparency of decision-making and that the local population had been communicated with, et cetera. Then we published those eight local authority names as they came online. We published them on our website so we could support that transparency.
In recognising the potential additional risk presented to people with care and support needs who live in those places where the easements were turned on, we prioritised our inspection activities. During Covid, we developed a new monitoring tool for having structured conversations with providers so we could seek assurance about the quality of care being provided. We tailored and prioritised those structured monitoring conversations to providers delivering care within that patch as well.
Simon Williams: The Local Government Association does not collect any data directly from councils; we do not have any power to do that. When councils notified of their decision to enact easements, that was directly to the Department of Health and Social Care, which would hold any information.
However, that does not mean we are not seeking to learn from experience. We have engaged with partner organisations, notably Think Local Act Personal, which gives a voice to people using services and carers, to seek to understand the impact. That has started off with a conversation with the eight councils that enacted easements and five that did not. There is some learning from that, alongside a bit of survey work that they have been able to do with some of their members. We have been able to draw a bit of learning from that, but we want to continue to do that. We are quite sure there will be more to draw out.
In terms of transparency, I know we are committed to being transparent about this. We have no reason to do anything else, other than to say we would want to be fully honest and up front with people relying on these services about why these decisions were necessary and the whole decision-making train.
Turning to your last point about justifying the decisions of the eight councils, the fact is that all eight enacted them and then, within a fairly short period of time, were able to stop enacting that. You could either interpret that as a positive thing, that as soon as they could they stopped doing it, or you could ask, “Why did they do it?” From my own conversations, I believe they were doing that on a precautionary basis. The fact is, we did not really know, as we went into this emergency, whether the Care Act was going to allow sufficient flexibility to make some of these difficult decisions councils were looking to make about prioritising care and support.
Some councils adopted a wait-and-see policy. Some councils felt it was better to make that easement decision right at the beginning. Both stances were entirely reasonable. It is entirely reasonable and I do not think there is anything to justify for councils that decided, on that precautionary basis, to switch on the easements, even if, in the light of experience, they then found that the Care Act gave them enough flexibility to do the prioritisation they needed to do.
Q46 Kim Johnson: Simon, did Think Local Act Personal provide you with any information about whether there was any adverse effect on disabled people as a result of the easements?
Simon Williams: It is very early days and we had a meeting with them yesterday, where they began to share some initial findings. I do not want to steal their thunder in any way. Clearly, there are some indications about impact. I do not think they would mind giving you a brief flavour of that.
Some of this was about process. In some cases, they would have liked there to have been better communication and even co-production about these decisions. There was a keenness to make sure that services get restored as quickly as possible, particularly for carers and people with mental health issues. There was a recognition of the unequal impact.
One of their recommendations, for example, was about digital inclusion and recognising in this situation that digitally excluded people are much worse affected. We will be very happy to share with this Committee a more substantive version of the report when it is available.
Q47 Kim Johnson: Written evidence might be useful to see. This is my second question. Do you know if any disabled people across the country have had any of their care packages reduced during this pandemic when the local authority has not triggered a Care Act easement? Does either of you have any data on the number of councils operating reduced social care?
As a former employee of Liverpool City Council adult services, I am aware that some people in the authority have had their packages reduced, particularly people with dementia, who have not been able to access day centres, which has an impact on their families. If you could tell us of any other cases you are aware of, that would be great.
Kate Terroni: Forgive me; we do not regulate—[Inaudible]—or day services.
Could I make a point about hearing directly from people? If people experience a reduction in their package of care, or if they experience poor quality of care, their first point to raise that complaint is with their provider or with the commissioner. However, we are really keen to hear about that directly as well, as a regulator.
We have something called “Give feedback on care”, where we encourage people to tell us directly about the quality of their care. That helps inform us about quality of services out there, where the risk is, but also where we may want to target our regulatory efforts. I encourage anyone who gets in touch with you or who listens to this and has a view about the quality of care they are receiving to also share that with us, so that helps inform our view of what is happening out there.
Simon Williams: Obviously, I would not know about what has gone on in every single council and the detail. First, some people will have a reduction in their service package anyway. It is a normal process as part of our philosophy about promoting independence that sometimes people do not need as much of a service as they did, particularly after a period of reablement. I would not be surprised if that process had continued in any case.
Secondly, of course there would have been certain categories of service that had to change, notably day centres. There was an issue around shared lives, where it was becoming difficult to offer a service in people’s own homes. In those cases, local authorities tried to offer people a substitute to ensure they were still getting care and support. Do I think that, in every single case, those using the service or carers thought that was not a diminution in the support they were getting? No, I doubt that. I am sure some people saw it as a loss, despite the absolute very best efforts that local authorities were making, and hence the point about our commitment to seeking to restore services as we can.
Q48 Kim Johnson: Sir Simon Stevens has said that the pandemic has shone a spotlight on longstanding weaknesses and lack of investment and resilience in the social care sector. As we know, it has been under-resourced because of austerity in the past 10 years and it is very fragmented. Do you agree? If so, what needs to change as a priority?
Kate Terroni: Since 2016, the CQC, in its annual State of Care report, has been calling for that long-term sustainable funding solution for social care, as have many of us in the sector. We have a responsibility around market oversight. The fragility of the sector has been well evidenced and documented over the last few years. What has been so noticeable about the pandemic is that is has absolutely magnified the issues with the system but also the good things.
In social care, it is about long-term sustainable funding. It is about workforce. Before Covid, Skills for Care told us that there were 122,000 vacancies in the social care sector. Turnover rates are up to 37%. We need to make social care, being a front-line carer, a career of choice for people leaving education. To do that, they need to have the reward, recognition and career pathways that mean they come into it as a profession and stay in it for 20, 30 or 40 years. It is about funding. It is about workforce.
There is also something for me about integration. We knew before Covid, and we talked about it in our Beyond Barriers report in 2018, that people experienced very variable joined-up care across the country. Where people have better outcomes, that is where health and social care are working together really well. They understand the local population. They understand the needs of people and they move their money and resources accordingly. The third thing is that we really need to see a consistent commitment to providing good joined-up care for people who receive health and social care.
Q49 Kim Johnson: Do we also need to consider not just being low skilled and low paid?
Kate Terroni: Absolutely, yes. The amount of focus that has been placed on social carers over the last 14 or 16 weeks has been fantastic, but that needs to translate into action. That needs to translate into appropriate rewards and recognition. We need to place the right value on it as a society and we need to ensure people have meaningful career pathways, so they stay in it as a career of choice.
Q50 Kim Johnson: This week we have heard about pay increases across the public sector, but sadly it looks like care workers are going to miss out because of the funding not going to the local authorities to enable them to have a pay increase. What are your thoughts on that?
Kate Terroni: Simon will probably want to come in on this as well. What is so fabulous about social care is the choice that is offered by it. The vibrant market that is out there has a lot of good things about it. Fragmented sounds negative, but it is a market provided by many providers and those providers are often private providers. They are not often local authority direct provision.
Often, the response is, “We cannot directly pay care workers more money because these are private organisations”. For me, we just need to resolve it. I have been a care worker early on in my career. We need people to take this on as a job, be able to pay their mortgage, be able to stay in it and feel suitably valued for the fabulous work they do.
Simon Williams: I agree with everything that Kate has said and, indeed, what Sir Simon Stevens said. On the funding, the LGA’s calculation has been that we reckoned about £2.5 billion more was needed for social care this year. Even after a comparatively generous settlement this year, there is still nearly a £1 billion gap, which rises to about £4 billion in about three years, so there is clearly a need for funding.
We would probably mention one or two other things. One legacy from the tragedies that happen to so many people who need these services is that we want social care to be recognised as valuable in its own right, both with the NHS and as an asset to the economy, as a real career of choice. Secondly, we want there to be more emphasis on early prevention and intervention, to learn and build on the great community resilience responses there have been during this pandemic, not in any way to take that for granted. We have learned a lot about what can be done with the right support and recognition, and we believe we need to build on that.
Thirdly, it is absolutely imperative that we do all this keeping the person at the centre. We have learned again a lot about what can be done sometimes if we have to turn away from some of our traditional service offers, listen to people and be flexible. We want to build on that.
There is then the final point that Kate has made about workforce. We would agree about the issue that it is very diverse, with a whole range of different providers and employers. People in the service may want different types of employment package and commitment. There is absolutely no doubt that, having said all that, people need to be paid more and need a much greater level of recognition. We hope that the care badge that has come out during this crisis will stay with us and be worn with pride both by people in the service and by others.
Q51 Kim Johnson: This is a final question to you both, with hopefully very quick answers. If you were a member of this Committee, what would you recommend the Government do about the emergency social care provisions when they come up for review in September?
Kate Terroni: With regard to the Coronavirus Act and the Care Act easements, we are really keen that these measures are in place for as short a period as possible. The last thing we wanted to see is the erosion of the Care Act principles, which everyone in the sector is behind.
Simon Williams: We are aware of how anxious this has made people. We are with Kate in saying it should be ended as soon as possible, but we must not think we are out of the woods yet. There is a lot facing us this winter. If we do that, we should not absolutely close our minds to the fact that local authorities will need to continue to make difficult decisions.
Q52 Angela Crawley: Can I thank each of the panellists for their contributions so far? It is great to hear the important work that is taking place, especially in healthcare. It is especially important when you consider the integration of health and social care in Scotland as a really positive example.
I want to turn to protecting disabled people during Covid. My question is specifically to Celia and Gill. The ONS data indicates that disabled women were 2.4 times more likely and male disabled people were 1.9 times more likely to die of Covid. Are your organisations taking action to understand the reasons for the disproportionate deaths of disabled people? Is there a case for a review? Who should carry that out? When would be the right time for that review?
Celia Ingham Clark: I understand that the Secretary of State has already asked Public Health England to carry out a review of the excess deaths during the Covid pandemic, particularly to help understand some of the reasons why there may be a disproportionate impact on different groups. That applies to disabled groups, including learning disabled groups.
The Chief Medical Officer has said that, when we want to try to understand what the impact has been, we have to look at excess deaths overall. It is quite difficult to tell the difference between a death from Covid and a death from something else that may or may not be linked to Covid. We will not have enough data to do an accurate analysis for some time yet.
There is also specific work about people with learning disabilities who have died. The University of Bristol is starting some work on that. We know that the notifications of deaths of people with learning disability have increased significantly. They have gone up by about 60% to 70% compared with the same period last year, if you look at March, April and May. The University of Bristol is going to look at 200 reviews of deaths of people with learning disabilities once they have had their initial review in the CCG. They are going to see what lessons can be brought out of that and shared more widely with the system.
The difficulty with Covid is that its impact is so nasty on so many disadvantaged groups. We know it has a massive impact in relation to age. It has an impact in relation to gender, in relation to ethnicity and in relation to all sorts of disability. It is really difficult and really important that we unpick that so we can see what we can do to protect people going forward, if there were to be a second wave or some future pandemic.
Professor Leng: We are looking nationally and internationally at NICE for any new analyses that might inform our guidance. To build on what Celia has said, when that review of this data has been carried out by Public Health England, we will take that and then determine whether we need to feed anything into our guideline by way of update to reflect that apparently disproportionate death rate.
Q53 Angela Crawley: Can I turn to Kate now? You published data on the deaths of people with learning disabilities and autism in the social care setting, specifically during the period of April and May, which showed a 134% increase on the same period last year. Has sufficient action now been taken on PPE, testing and infection control measures to ensure that disabled people in the social care setting are not at a disproportionate risk?
Kate Terroni: We published that data, as you say, between 10 April and 15 May that showed that significant increase. When we published it, we called for the expansion of testing. Testing was happening for asymptomatic people in care homes, so predominantly people aged over 65. We called for the expansion of that testing to adults of working age. We were really pleased when we saw that happen.
Testing for adults of working age in care homes is now happening. In the next few weeks, that should be expanded out to adults in supported living services where there is a communal area that people spend time in. As soon as we properly understood the impact of Covid on adults with learning disabilities and/or autism, there was a need to get that timely access to testing.
With regard to PPE, as a general rule it is a lot better now than it was in the beginning. We are publishing a monthly insights report about what we are seeing as the impact of Covid-19 on health and social care settings. Our first insight report focused heavily on the impact in social care. That highlighted key issues around testing, PPE and workforce sickness absences. Providers are reporting an improvement in PPE. It is not completely resolved, but it is a lot better than what it was. My hope is that we see that expansion of testing. There is a plan for that to be rolled out to adults of working age in supported living settings in the next week or two.
Q54 Angela Crawley: Are you continuing to monitor the deaths of disabled people in social care? Can you update us on that?
Kate Terroni: We are monitoring it. It forms part of our monthly insight reports. We published our last report about two weeks ago and in the next one there will continue to be a focus on the numbers of adults with learning disabilities and/or autism who die with Covid as the cause of death.
Q55 Angela Crawley: There was a feeling among many within the disabled community and those who work in disabled social care that they were forgotten in the beginning of the pandemic. Do you understand or share that view, or do you have your own view on that?
Kate Terroni: I think about Gill’s earlier comment that, when we think back to where we were in the beginning of March, where the reasonable worst case scenario was reporting a potential 500,000 deaths, the focus was on freeing up acute hospital capacity. There is a whole lot of logic around that. Again, in the early stages of this pandemic, the thoughts were that older people with multiple health conditions were the ones most at risk. As the weeks unfolded, it became apparent, and obviously we published that data, that there was significant concern about the impact on adults with learning disabilities and/or autism. I can absolutely hear and accept that those have been the views of people.
There are a couple of things I would say. When we have been made aware of issues affecting this group, we have taken actions. For example, earlier on in the pandemic, it became apparent that there were some examples of a blanket issuing of “do not attempt resuscitation”. Celia mentioned that earlier. When we became aware of that, we issued a joint statement with the British Medical Association, Royal College of GPs and the Care Provider Alliance to make it absolutely clear that this should not be used in any circumstances and that we would take action as and when needed.
We have continued to have regular conversations with those providers of services for adults of working age. Over the course of the pandemic, we have spoken to 20,400 providers to establish how they are ensuring they provide high-quality care during this time.
Q56 Angela Crawley: This is the final question from me. Simon may also wish to comment on this, because you touched on it earlier. How confident are you that the sector as a whole, including those in supported living, is prepared now to better protect people, should there be a second wave of this virus?
Kate Terroni: We know that so much of preparedness for a potential second wave or winter is about how health and social care have come together to support individuals. Across the country, where there were those strong relationships prior to Covid, we have seen a better response than in other parts. Because of that, we are undertaking a series of what we are calling provider collaboration reviews.
We are currently talking to 11 systems across the country to find out what has worked well in how health and social care providers have come together during the pandemic and what the barriers to joint working have been. That will inform a report that we will share, which will have recommendations about what we need to see in place to ensure, as best as possible, a weathering of a potential wave 2 or a particularly difficult winter.
Simon Williams: To add some specifics, there are various areas in which to be prepared. Testing remains a work in progress from our point of view. On PPE, I agree with Kate that we have come a long way. We are in a much better position than we were, but there remain issues about the cost of it, certain very specific items of PPE and making sure that people using direct payments and personal assistance have equal access to this. We still have a little bit of work to do on that.
We believe we handled hospital discharge well in March and April, in terms of clearing beds very well, but we are still somewhat anxious that, in some places, that was at the cost of inappropriate admissions to care homes. We have been continuing to work with the NHS. Some further guidance will be coming out next week. We know they share our view that people should go home whenever possible. In terms of preparedness, we want to make sure that every place in the country is as well supported as possible to actually operate that philosophy.
Finally, we have seen councils broadly being able to prioritise, make decisions, switch things around and reshape services, which bodes well in terms of preparedness. We have to remember that, in the winter, where ordinary flu is combined with local outbreaks and possibly a second wave of Covid-19, we may face certainly different and maybe greater challenges than what we have seen already.
Q57 Chair: Can I take both Kate and Simon back to the issue of PPE? We heard from Ministers last week, from one in the Department of Health and Social Care and one in the Ministry of Housing, Communities and Local Government, about the supply lines of PPE. I wondered if you would comment on the two bits of evidence that we had.
Certainly from Jo Churchill at the Department of Health and Social Care, there was an acknowledgement that it was an enormous logistical operation and that various parts of the country were running, in her words, “extremely hot”, but they operated the system until we got much more of a handle on ensuring that supply lines were fluid and robust. Would you now describe those supply lines as fluid and robust?
The second quote is from Chris Pincher at the Ministry of Housing, Communities and Local Government. Chris said “Although there were challenges with, for example, PPE, nobody effectively ran out”. Did either of you have anything you would like to comment on those two statements from Ministers?
Simon Williams: Let us come to the last point first. That is arguable. I meet with providers at least once a week, so it has been a live topic of conversation. I know providers that said, “Technically we may not have run out, but we were using bin bags instead of aprons. In the very early stages, we were having to duck and dive, and be very adaptable and flexible, in how we tried to protect people”.
People had to do a little bit of make-do in following the official guidance. Yes, it is true that when providers said, “We are down to absolutely nothing”, emergency drops were done with local resilience fora. That got through to providers and it worked, but I would not like to give the impression that at all times providers had absolutely everything they needed.
On the general point about supply lines, we are still trying to learn the right balance of central ordering and procurement that gives all the ability of scale, and that is really important, with flexibility at a local level about how that is drawn down. Only this morning, I was in a conversation with providers who said they would want to retain that flexibility. They welcome the fact that Government are doing everything they can to make sure there is overall enough quantity of PPE, but they would prefer to have it in their own hands, both themselves and with their local partners, as to how they draw that down.
Kate Terroni: I do not have a huge amount to add. There is something called a capacity tracker, which is where providers tell NHS England about all sorts of things Covid-related, including PPE. We at the CQC developed something called a homecare tracker, where we could also have that daily snapshot from homecare providers. In that, providers can tell us whether they have more than 14 days’, seven days’ or less than two days’ supply of PPE.
We are not seeing the numbers of less than two days now that we did in the beginning. In the beginning, there were many examples where, in conversations with providers, they would be down to the last bits of PPE and we would end up ringing other providers to share supplies, et cetera. It was exceptionally challenging in the beginning. It is better now.
Q58 Chair: What is the impact of increasing cost on providers?
Simon Williams: We did some work back in May with providers and with ADASS, where we worked with industry specialists. We came to an estimate of about £6 billion of overall extra cost on providers over six months, of which about £4 billion was PPE, so it was a big number. Obviously we have had some very welcome funding to help mitigate that.
It is fair to say that, although, as Kate says, we are in a much better place in terms of overall provision and we are not hearing of providers down to their last two days, they still worry about the upward cost that has happened, in terms of both unit cost and the measures they have needed to take to operate safely and follow guidance.
Q59 Chair: Can you put a number on that? There is £6 billion additional cost, two-thirds of which is PPE. What percentage of that has been covered by the additional funding that has been provided?
Simon Williams: In terms of the funding into local government, about £1.5 billion has been committed to social care. That will generally have gone to providers and a large percentage of that will be for PPE, but not entirely PPE. It is for staffing and other things as well. Welcome though the funding has been, there still remains a gap between costs incurred and how much money has flowed through so far.
Q60 Peter Gibson: Good afternoon. My first question is directed to Celia. Can you describe the background to NHS primary care services encouraging social care services and individuals with learning disabilities to consent to “do not attempt to resuscitate” notices, effectively waiving access to treatment for Covid-19?
Celia Ingham Clark: We need to be absolutely clear that we do not think it is appropriate to use blanket “do not resuscitate” notices in any circumstances. Discussions about access to treatment and admission to hospital need to be taken on an individual basis, involving the individual themselves, their family and carers, plus an understanding of their normal health and what the acute situation is for them. We do not approve of blanket “do not attempt resuscitation” notices.
In fact, in April last year, my boss, the national medical director, Stephen Powis, wrote a letter to the system, making it clear that blanket “do not attempt resuscitation” notices were inappropriate. There had been some media interest at that stage, where they had apparently inappropriately had “do not attempt resuscitation” notices for an individual with learning disabilities. That had gone to the system well before the Covid pandemic arrived.
When the Covid pandemic arrived, we took a number of steps to try to make absolutely certain that such blanket approaches are not used. The standards and quality of care have to be maintained, even in pressurised situations.
First, the speciality guide for managing people with learning disabilities that I mentioned earlier, which was published in March, made it very clear that there needed to be an individual approach. Secondly, the national director for mental health and their national clinical director, plus the medical director for primary care, wrote a letter to the system on 3 April, reminding people, particularly GPs, not to use blanket “do not attempt resuscitation” approaches and of the importance of the individual approach. There have been further messages since then in primary care bulletins.
Looking forward, we have to do what we can to make a better understanding of what we are talking about in this space. NHS England and NHS Improvement are currently working with stakeholders to produce some written information to improve the public understanding of what is involved in a “do not attempt resuscitation” notice, including how to raise concerns about it. We are hoping to publish that soon.
Q61 Peter Gibson: Do you believe that your guidance reached everybody?
Celia Ingham Clark: As I mentioned, the guidance has gone out in three or four different ways. It definitely was received across the system. It should have been read by all of them. There are local check-ups in the way that people can raise concerns. We did not just send it to the NHS. We sent it to the stakeholder groups and the voluntary sector that support people with learning disabilities as well, so that they have the opportunity to raise concerns if such a thing is suggested.
Q62 Peter Gibson: What review, if any, is taking place that the advice you issued was actually followed throughout the system?
Celia Ingham Clark: We have done repeated reminders, particularly to GPs, about this. The learning disabilities cell within our response to Covid has been listening to stakeholders and experts by experience to see what has been coming back on this. Earlier this week, the national clinical director told me that the concerns coming from individual clients at the beginning of the pandemic are not being heard now.
Q63 Peter Gibson: So there is not going to be a review.
Celia Ingham Clark: I am not aware of there being any plans for a review.
Q64 Peter Gibson: What lessons do you believe could be learned from the experience of the problems with the “do not attempt resuscitation” blanket approach that we saw in certain parts of the country during Covid-19?
Celia Ingham Clark: The fact that it was such a big emergency at the time and we had heard, as you heard earlier, about the likely demands on the health service meant that people on the ground felt in a particularly stressed situation about whether the health service would be able to cope with that was coming. The NHS was initially asked particularly to focus on ensuring there was enough capacity for ITU and acute beds for people going forward. I suspect that meant that some people took their eye off the ball at a local level, and that is really regrettable.
The lessons that need to be learned are that, whatever the degree of pressure that exists, you have to remember first principles. Those of us who are doctors, like me, have to stick to the tenets of good medical practice published by the General Medical Council. We have to take an equitable approach to managing care and a personalised approach to individual patients. We have to keep repeating that message because that is the really important thing to do in order for us to demonstrate humanity.
Q65 Peter Gibson: Could you tell the Committee what steps are now being taken to review medical records of people who did have these notices affixed to their notes after this pandemic?
Celia Ingham Clark: I am not aware of any steps that are being taken as you suggest.
Q66 Peter Gibson: There could be blanket DNARs sitting on people’s medical records that should not be there.
Celia Ingham Clark: When people are being discharged home from hospital, the GPs are looking at what comes in the discharge note from hospital. If anything had been put in in hospital, and I have no evidence that that was the case, the GPs are reviewing them at the point of discharge. That has been advised through the primary care bulletin.
Q67 Peter Gibson: Is it your plan to issue any further guidance to ensure that a review takes place for lessons learned and that these notices that should not be there are removed from medical records?
Celia Ingham Clark: I am not aware of any further plans at the moment. That is something I can take away and discuss with my colleagues in the learning disability cell.
Q68 Peter Gibson: Would you be able to write to the Committee with your advice in respect of that?
Celia Ingham Clark: Yes, I can.
Q69 Kim Johnson: I want to ask a very quick question, but it is related to a previous question. It is to Simon and Kate and it is around funding and the social care sector. We, as local authorities, provide lots of funding to the private sector to deliver public services. I wanted to know from your point of view whether we should consider looking at developing a national care service. Should we look at trying to insource social care back into local authorities?
Kate Terroni: Prior to the job I am in now, I was a director of social services of a large county council. When providers exited the market, for a whole variety of reasons, we had many discussions about whether we should have an in-house function, which we did not have at that time.
It is really important that we do not make big decisions in the middle of the pandemic on this. It is also really important that we hold on to one of those main principles of social care, which is about choice. Maybe I want a direct payment from my local authority and maybe I want to pay my neighbour down the street to provide my own care. Everyone in the sector is up for social care reform, but now is probably not the time to jump to what that model should look like.
To the previous question on DNARs and how we can be assured they are not on people’s records, I will add a little bit about CQC’s contribution. On many occasions, it was social care providers that flagged to us the issuing of “do not attempt resuscitation”. It is often the registered manager of a care home who raises the red flag.
In our discussions with those 20,000-plus providers, and when we go out and cross the threshold to regulate individual services, our focus is on how that service is providing individualised, personalised care. There is another safety net option, in those discussions, and when we are reviewing care plans and talking to people about the quality of care, to spot the potential issuing of “do not attempt resuscitation”, if it has not been flagged to us already.
Simon Williams: I certainly agree with Kate that now is not the time to be making any huge decisions about the future structure of social care. On the point about a national care service, local authorities have different mixes of services.
This is the main point we would make: let us look at the reasons why people call for that. If it is about, for example, unwanted variation, or consistency, maybe we should also look at big services to ask, “How much has that driven out variation?” We believe in personalised services that offer choice. We know that councils deliver that in a whole variety of ways. We are up for a debate about reform, but not right now.
Q70 Bell Ribeiro-Addy: My questions are going to be about disability, equality considerations and reopening NHS services. Most of them are for Celia, but if anybody else would like to comment that would be great. How would you say disability equality is being taken into account in the reopening of NHS services?
Celia Ingham Clark: We are developing restoration guides centrally. We have already developed and published the one for children and we are shortly due to publish the one for adults. There is an equality impact assessment inherent in the development of those guides because we need to ensure an equitable approach is taken. It is part of the systematic approach.
Q71 Bell Ribeiro-Addy: We have heard from Mencap that annual NHS health checks for people with learning disabilities are incredibly important in addressing health inequalities for this group. Will they be prioritised when reopening NHS services? When might we expect them to restart?
Celia Ingham Clark: At the start of the pandemic, we put out a prioritisation guide as far as community services were concerned. That basically put individual services into either “do not stop under any circumstances”, “keep going if you can” or “you ought to stop these during the pandemic”. I have to say I think there were very few in the last category. The annual health checks for people with learning disabilities at that stage were in the “keep going if you can” box, so some providers were able to continue to do them, but many were not.
That was partly because of staff availability, because of course there was increased sick leave and many staff were doing other key work at that time. Some of it was to do with the risk associated with actually meeting the individual person who has learning disabilities face to face and the risk that you might pass infection on to them. I am sure that a big backlog built up during that time.
We have done several things to try to get those going again. First, Simon Stevens wrote a letter to the system as early as the end of April, encouraging the restoration of those sorts of services. Then, in May, the primary care bulletin sent out the same message again. More recently, we have actually announced seven exemplar sites where they are promoting new ways of working to try to restore these services, perhaps in a more flexible way, and aiming to get the percentage of people with learning disabilities who get these annual health checks over 75%, which it has not been to date.
The reason this is particularly important is that people with learning disabilities have an increased risk of dying from physical causes and, in particular, respiratory infections and sepsis. It is absolutely key that we improve their physical health in order to protect them. We are also training 5,000 paid and unpaid carers to spot early signs of deterioration in people with learning disabilities. We are working with the Race Equality Foundation and Learning Disability England to understand and act on any barriers faced by people from a BME background who have a learning disability as well. There are a variety of ways in which we are trying to restore those health checks, which are really important, as soon as possible.
Q72 Bell Ribeiro-Addy: Professor Leng might want to come in on my next question as well. Ayla Ozmen, representing Action on Hearing Loss, expressed to this Committee the difficulty presented by the increased use of face masks for those with hearing impairments and the need to approve clear face masks to aid lip readers.
As face masks become mandatory in many aspects of life, and as NHS services begin to reopen, the need to approve clear face masks is increasing. Last week, Jo Churchill, the Health Minister, told us that the Department was looking to procure clear face masks. Can you update us on this, in terms of numbers and perhaps dates?
Celia Ingham Clark: I cannot give you numbers, I am afraid. I know that the various charities associated with hearing loss wrote to the Chief Nursing Officer and the Chief Nursing Officer responded, recognising the importance of being able to provide clear face masks and/or other ways of enabling communication for people who normally rely on lip reading.
Nationally, I understand that the NHS supply chain, run by the Department of Health and Social Care, has already procured clear masks. At the moment, they are going through safety checks with them to make sure they meet the regulatory standards and they are intending to distribute them in early August.
In parallel with that, one of the charities, called SignHealth, is offering a remote sign language interpretation service for free, in order to help people access communication during this time. All these things have to be taken really seriously because of the Accessible Information Standard that has been in place as a legal requirement for providers of health care for several years.
Professor Leng: There is not really anything I can add, because we have not been asked to issue any advice to the system on face masks. However, I absolutely understand the issue for people with hearing loss.
Q73 Bell Ribeiro-Addy: Which health services do you think will have access to clear face masks once they are put in place?
Celia Ingham Clark: They are required across health services.
Q74 Bell Ribeiro-Addy: So we expect them to be available to everybody.
Celia Ingham Clark: I do not know the mechanism for distribution that the Department of Health and Social Care is planning, I am afraid. I imagine that there is not an inexhaustible supply, so there is probably a question of whether it is better for the supply to go via people who work closely with individuals who have hearing loss versus a blanket approach. You could imagine routes that involve use of the relevant charities or support organisations for people with hearing loss. Often the carer who is working with the individual is the key person the individual needs to be able to lip read from.
Q75 Bell Ribeiro-Addy: Finally, speaking more generally on long-term health conditions, we know that the NHS had to cut down on the number of these and all the treatments have fallen by what is estimated to be over 60%. This has resulted in a large backlog of people waiting to continue treatment for their long-term health issues. A backlog of between 8 million to 10 million to the end of the year has been estimated. Is there a plan set out by NHS England to deal with the backlog as services begin to reopen?
Celia Ingham Clark: Yes, a huge amount of work is being done to try to ensure the backlog is addressed in an appropriate way, with appropriate prioritisation. Some of that prioritisation will be to do with the urgency of the condition the person is experiencing. Some of it will be to do with the individual circumstances of patients. Many provider organisations have already started to go through their waiting lists and make an assessment in order to prioritise those patients.
They are also working collaboratively across integrated care systems so that, if it is helpful to direct some people towards one site and others to another, it may be easier to go forward in that way. There are some really interesting examples of collaboration that are happening in this space. It is an absolutely massive task, because not only do we have to deal with the backlog, but we also have to deal with the new referrals now coming through into the system. It is going to take us a long time to catch up.
Q76 Bell Ribeiro-Addy: To follow on, finally, are there any targets being set for this or is the plan just to work through the backlog?
Celia Ingham Clark: NHS England and NHS Improvement are doing what they can to enable local systems to get through and catch up as quickly as they can. I do not think specific targets have been set. It may not be appropriate to do that because, at this stage, we do not know how big the impact of Covid-19 is going to be this winter.
If we were to get a surge such as the surge that we had earlier this year, it might be very difficult to keep routine services going, as it was this spring, notwithstanding the learning we have so far. We are working on trying to get things up and running and get the productivity side of it running as smoothly as possible, while ensuring we have a prioritisation angle in that. Then we are going to have to see how it goes over the next few months.
Chair: Can I thank all the witnesses for their evidence this afternoon? If there is anything you would like to add in writing, please feel free to send it in to the Committee. It would be much appreciated.
Examination of witnesses
Witnesses: Ali Fiddy and Charlotte Ramsden.
Chair: Can I thank the two witnesses for joining us this afternoon? I am conscious that you have heard some of the previous witnesses and I will not go through the issues about technical problems; we hope we will not have any more. Thank you for joining us this afternoon for this inquiry into coronavirus and its unequal impact on disabled people and their access to services.
Q77 Nicola Richards: My first question is to Ali. On 1 July, you told the Education Committee that children and young people with special educational needs and disabilities but without an education, health and care plan had been forgotten about, that DfE guidance had been silent on the issue and that many in this category had been left with no additional support at all. Has the Department done anything in the last two weeks that has reassured you on this situation in particular?
Ali Fiddy: No, there has not really been any movement in relation to children and young people with SEN support. Of course, that is the vast majority of children and young people with SEND. That group of children and young people have their needs met through their school’s existing resources under this system called SEN support.
We know that very many children and young people at home during lockdown were not provided with any education that could meet their needs, including those with education, health and care plans. Learning materials and resources were not differentiated, which would be quite a common approach taken to supporting a child under SEN support.
Actually, the inadequacy of SEN support more broadly is one of the contributors to the crisis in SEND provision more generally, because it is not clear what good provision looks like in the context of SEN support and funding for SEN support is not ring-fenced within school budgets. That is one of the particular challenges. That leads to more parents feeling that the only way to secure guaranteed additional support for their child is to seek an assessment with a view to securing an education, health and care plan.
Q78 Nicola Richards: My next question is to both of you. Are you aware of schools that have continued good SEN provision throughout the pandemic? What does good look like in these circumstances?
Ali Fiddy: If you are thinking about children and young people with education, health and care plans, we know that provision has been patchy. We know that there have been some areas where children and young people have received very little support and provision. Families do not come to us at IPSEA when things are going well, so my ability to talk to you about where there have been areas of good practice and where schools and local authorities have been getting it right is incredibly limited. That question is probably much better directed at Charlotte.
Charlotte Ramsden: That point is really, really important, because we tend to hear more when things are going badly than when things are going well. No one would say that we have got this right for all children, but we are aware of extensive attempts by both school and multiagency partners to support children at SEN support level during this crisis.
At the point that schools were notified that they were going to close to all but vulnerable children and key worker children, they did an intense amount of preparation in that very short window to send children home with packs of learning material, access to online material where they could access that and paper materials where they did not have digital access.
Those with SEN support were not part of the vulnerable cohort that had an entitlement to a school place during that period, but the SENCOs in schools were very involved in liaising with the families of children at SEN support level within mainstream schools. All schools were working at the level below those identified as vulnerable to that Government criterion to set up arrangements to stay in touch with their definition of their vulnerable students. That involved a significant proportion of children open to them at SEN support level.
During that lockdown period, there was close communication from the best schools, I could not say from all schools, but from the vast majority of schools with those at SEN support level at least on a weekly basis and sometimes more. We had multiagency connections and communication around that cohort, so that other people who were providing support through early help services in the local authority or levels of health support were having communications around those children and keeping in touch. Where welfare concerns increased for those children, they were referred to children’s social care.
In terms of the differentiation of materials, that was hugely varied. Where possible, schools were working on that, but obviously remembering they worked in an incredibly intense and short time period to prepare for lockdown. Materials kept being topped up throughout lockdown across the system, so that continued for those at SEN-support level as well. Depending on which year group they were in, there was then the opportunity for those children to come back into school if they were in those priority year groups from the beginning of June. We found that some were keen to do that and some were not.
It has been a really mixed picture in terms of parents’ willingness to reengage with the education system after so much anxiety, as well as children’s. There is a really mixed picture in terms of what level of support has happened directly, face to face with children going back into school and what has continued on a virtual basis.
In terms of next steps, we are learning from everything that has happened in this period that will hopefully support the return to school in September. Those on education, health and care plans in mainstream settings, as with those in specialist settings, did meet that classification as defined by Government for vulnerable children who were entitled to the option of a school place.
Whether they came into school very much depended on Covid risk assessments as to whether that was an appropriate course of action for them. Those were done as a mixture between schools and local authorities. Some of those children were risk assessed as, “They will be better in school” and returned, and some were risk assessed as staying at home. Obviously, parents were involved in the co-production of those plans.
Where children have stayed at home, that was kept closely under review so, while at the beginning very few chose to take up their place in school, others did come back over time. There was a mixture there in terms of schools being able to cope and schools that could not, and the volume of children they could accommodate during that time.
Ali Fiddy: It is very positive to hear that there has been some good practice. We have had an overwhelming volume of calls from families who felt completely abandoned by both schools and local authorities. In the evidence that I gave to the Education Committee a couple of weeks ago, I talked about some very clear examples of schools unilaterally making decisions around risk assessments and utilising that risk assessment process to keep children and young people out of school who are perhaps deemed as more difficult and challenging, rather than it being based on the criterion it should have been based on, which was around safety.
Charlotte Ramsden: I absolutely agree with that. There is a totally mixed picture in terms of how schools felt able to cope with those children whose behaviour is complex and potentially challenging. I can only speak for my own local authority on that. Where we were aware of those issues, we intervened and negotiated around them, but that has been a very mixed picture across the board, so I totally agree that that has been very challenging.
Q79 Nicola Richards: In my constituency in West Bromwich East, I have visited four schools recently in the last couple of weeks and all of them had fantastic provisions in place for especially SEN children. Charlotte, will you be doing any work around the best practice from schools that have done well in this? Will you be gathering that information? It could be likely that schools are in this position again, maybe even towards the end of this year. It is important that we know how best to deal with it.
Charlotte Ramsden: Yes, absolutely. Children with SEND are a key priority for ADCS and it is covered through a number of our committees. We have an education committee, which is a mixture of directors of education and directors of children’s services. They are looking at this from the side of inclusion, how best to meet children’s needs in the mainstream and maximising inclusion, whether that be with schools fully open, partially open or in lockdown.
We also have a healthcare and additional needs committee, which is looking at the specific needs of individual children and the relationship with health, making sure that we work in partnership to do what we can to learn from everything that has gone well, continue to share good practice where that has happened but also work together to address things that are of concern. As you have heard, there do remain things of concern and it is a mixed picture.
We are actively involved in dialogue with the Department for Education on those topics as well. We have very frequent meetings with them on a generic basis but also specifically in relation to education. Those things are part of an active, ongoing discussion and review.
Q80 Nicola Richards: To what extent have these problems been a consequence of pre-existing problems in the system identified last year by the NAO and the Education Select Committee? How confident are you that the current system can be fixed? What changes are needed most urgently?
Charlotte Ramsden: We share all the concerns about recognising that the SEND system does not meet the ambition that was set out for it in the Children and Families Act. We collectively, as a system, are not yet delivering on that ambition, which is about supporting more children and young people to achieve their potential and to have fulfilling lives, as close to home as appropriate and possible, both as children and as adults. Throughout the time since the Act was enacted, there have been a huge amount of people caught up in process issues—“Whose responsibility do issues belong to?”—and looking at the appropriateness of provisions to enable children’s needs to be met well.
We welcome the SEND review and the fact that those things are being further addressed there. We have made representations as to the areas we think really need to be addressed. We are very well aware of the variability of the effectiveness of joint commissioning, for example, and the engagement with health colleagues is very mixed in the system.
We are very well aware of the complexities between the desire for inclusion in mainstream and, at times, the mainstream system not appearing set up to be inclusive. It is based on exam results. There are difficulties about managing challenging behaviour. We hope that the new Ofsted inspection framework will encourage addressing that, but we are also aware of the massive budget pressures in terms of doing this well.
You may well have seen the budget challenges that were identified by Isos in a report that it undertook, commissioned by the Local Government Association, which identified a huge funding gap of potentially £1.6 billion by this year in relation to delivering against those needs. There is a huge amount of work to be done to understand where we have got things that are working well, how we can learn from them and what we need to address.
Of course, the impact of Covid and lockdown has both delayed some of the work that was happening to address those issues and exacerbated some of them. With fewer schools being open for fewer people, health colleagues being drawn into Covid responses or less able to see people and fulfil their mainstream activities, and all our services being delivered virtually as opposed to face to face, the pressure that has built up on children and their families, particularly as this goes on over the length of time that it is doing, is just immense. Addressing some of those things now has become really urgent, which is why it is such a high priority for us.
Ali Fiddy: When we have talked about the fact that the provision during lockdown has been so patchy, that is a reflection of what things are like in normal times too. You talked about the inquiry completed by the Education Committee last year. There has also been repeated criticism from the local area SEND inspections, which are the joint inspections undertaken by Ofsted and the Care Quality Commission. They have found really significant weaknesses in many local areas’ effectiveness at identifying, assessing and meeting the needs of children and young people with SEND.
We have seen those kinds of issues around the inadequacy of SEN support and the lack of provision at that level, issues around accountability, at both a school level and a local authority level when they get it wrong, a lack of understanding around what the law requires. We have seen that under these temporary changes to the law as well, where a high volume of local authorities further diluted their responsibilities towards children and young people even prior to any of the temporary legislative changes and then continued to do so afterwards.
While many of those policies that have been introduced and were publicly introduced in local authority areas have, I am sure, now been withdrawn, we suspect that that practice is continuing in some areas. We are concerned about the number of children and young people who were impacted by that unlawful practice early on and the extent to which local authorities have followed that up with the families concerned to ensure that they are meeting those obligations that they should have been meeting throughout.
I would agree with what Charlotte has said around the issues around joined-up working across the various agencies involved in supporting children and young people with SEND. That has not come to fruition since the reforms were introduced. Let us not lose sight of the fact that these reforms, which I still commonly hear people call “fairly new”, came in in 2014.
The reforms were absolutely the right ones. They are focused on meeting the needs of children and young people with SEND in a more holistic way, but the implementation of those reforms and a lack of compliance with the law, often at the most basic level, has been a real problem. That is a reflection of what we have seen in these challenging times as we have been in lockdown. We are concerned about whether this will be used as a first step in seeking to permanently dilute local authority and school obligations towards this group of children and young people.
Nicola Richards: Charlotte, did you have something to add on that?
Charlotte Ramsden: I am happy to come back on the dilution of responsibilities if you want me to. I am not sure if that will come up under a later question. I was just going to respond specifically in relation to SEND inspections and the outcomes of those inspections. I would agree that they are a really mixed picture, but it is important to recognise that, for some authorities, those inspections have been very positive and the outcomes have been very strong. As ADCS, we are looking at: “Where are those strong inspection outcomes and what learning can we share in relation to those?”
Importantly, this is not just about local authorities and schools. This is absolutely about health colleagues as well. A lot of the issues raised in these inspections are in relation to the actions of health. It is really important that this is a multiagency consideration and does not focus just on local authorities or, indeed, on schools. It absolutely needs that multiagency approach, consideration and response. As I say, I am happy to come back on those wider issues or wait for a further question on that.
Q81 Chair: Can I take Ali back to the comment she made about services being inundated with calls? Do you have any statistics around whether problems were arising in maintained schools or academies? Was there a difference in the quality delivered by the two different categories?
Ali Fiddy: Sorry; I was having a little trouble hearing you there. Was that point about where schools perhaps have not been delivering in the current situation? I was not quite sure.
Chair: Sorry, we do have sound problems—with me, apparently, but nobody else. This is what I am trying to get to the bottom of. You have both said there has been a mixed picture of delivery of services to young people with special educational needs. I am trying to ascertain whether you might have any evidence as to whether there is a difference in the delivery between the maintained sector and academies.
Ali Fiddy: From our perspective, when you are talking about children and young people with education, health and care plans, the legal obligations sit with local authorities. They do not sit with schools in the same way. That responsibility to ensure that needs are assessed and that provision is delivered sits all back there with local authorities. When I am talking about issues in schools, it tends to be around the process of risk assessment during this lockdown period and also SEN support.
The focus of our work tends to be on the majority of children and young people with education, health and care plans. I do not have any statistics specifically about the split of types of school.
Charlotte Ramsden: From a local authority perspective, we have partnership relationships with all schools, but our ability to direct things in relation to MATs is significantly less than in relation to our maintained schools, particularly in relation to directing admission. Where there is a child with an education, health and care plan whose choice of provision is an academy, if that academy does not wish to take that young person, we do not have the power to direct it, whereas we have the power to direct it in a maintained school. That is an action that goes through the regional schools commissioner through to the Secretary of State.
From a director of children’s services perspective, we are very keen that, if we have responsibility for enacting education, health and care plans, with that comes the authority to do that, so that we can speedily make sure that those young people are admitted to their school of choice. In many cases, probably most cases, it is not an issue but, when it arises, it causes significant delay in the implementation of a plan for a child.
Q82 Elliot Colburn: Thank you to our witnesses. I wonder if we can drill down a little more into the relaxation of the EHCP duty. This was probably answered in the last set of questions, but there seems to be a wide variation across the country in the interpretation of the reasonable endeavours duty, which has been introduced in the Coronavirus Act.
From evidence I have received from people in my own constituency, particularly the Sutton EHCP Crisis group, there seems to be a wide variation in just our borough between schools that are providing more or less all the provisions of the plan that that child had in place in the first instance, and schools that have turned away children with an EHC plan altogether during this pandemic, saying that they cannot meet their needs while the pandemic is ongoing, all under the auspices of being a reasonable endeavour.
First, as an obvious question, do you agree that that variation exists? Secondly, is the guidance that has been issued by central Government clear enough to both local authorities and schools to interpret this duty?
Charlotte Ramsden: That is really, really interesting. From our perspective, the relaxation of the duty was very welcome, because it was reflection of the reality of what was possible and achievable in the midst of a crisis lockdown. We need to remind people that, literally in the space of a few days, we went from schools being open and face-to-face delivery of services to virtual delivery of services and schools only open to a really small number of children. That was in unprecedented circumstances, where we needed to respond to and manage all the risks from a Public Health England perspective, in terms of not transmitting the virus. Of course, some of the children and their families, both parents and grandparents, would potentially be at high risk in that.
It was an incredibly complex picture within which we were trying to sustain as much of our service and support to all children, including those with education, health and care plans and SEN support. For us, the relaxation of the duty was a reflection of reality of what was possible. It gave a generic set of guidance, within which there was an expectation that there would be local flexibility and response. The local flexibility and response related to who was actually in work, because we had staff who were shielding and staff who were ill. There was flexibility, particularly within schools, about the availability of staff to deliver support on an education basis.
We had a variability of health availability. In some places, health staff were doing Covid duties and there was some national direction around what those staff could and could not do during the pandemic as well. We had variation in terms of doing risk assessments around schools, where obviously buildings vary, and then individual risk assessments for individual children.
What was aimed to happen was that we would make local interpretation and use the relaxed guidance as little as possible. That is what we tried to do. We have maintained our duties in full where that has been possible. Where it has not, we have used that more relaxed endeavour. The success of that and the variety of the quality of that is indisputable. It will have been better done in some places than in others, but the intention has always been to continue to deliver the best possible services but on a flexible basis. As I say, that will have had a mixed response. I know there have been lots of negative responses to that.
In terms of whether they were the right relaxations, they were the right relaxations for helping with the flexibilities we had to tackle. What it caused, and again it depended on how relationships worked in different places, was a huge amount of anxiety and assumption that it would be seen as an excuse to stop doing things. Where relationships were already difficult, there was an assumption that that was the case.
Where relationships, particularly co-produced relationships with families, were stronger, we were much more able to have those dialogues and ask, “What can we do to help you, given that your school place is not going to be available? We can provide this in terms of education, this in terms of contact and this in terms of a short break arrangement”.
We have tried to make the best of doing the best for individual children according to the local context of the place, individual schools, local authorities and availability of health colleagues. It was inevitable that there would be a significant variation of interpretation, because local circumstances would be and have been very different in different parts of the country.
Ali Fiddy: To be really clear, the dilution of the legal obligation to deliver special educational provision to a reasonable endeavours duty was a dilution of the duty on local authorities. There was no dilution on the part of schools and, in fact, that is not a legal obligation of schools in normal times. The overarching responsibility to ensure special educational provision is in place sits with local authorities. It is important not to confuse that because it is often quite easy to just push responsibility to schools when, in fact, the local authority has the responsibility in law.
Something similar has happened around risk assessments. Actually, risk assessments were not intended, according to the guidance, to just be done unilaterally by schools, but the reality is that that has happened in very many places, certainly from the nature of the calls we have received at IPSEA.
I appreciate what Charlotte was saying about the fact that there was a need for health staff to be diverted who perhaps were not able to provide special educational provision, but I do not think we are in that position now. It has been some time since we have been in that position and lots of those health staff have been able to come back into their usual roles.
Many families were very patient and tolerant, certainly for those first few weeks that we were in lockdown. To also be very clear, Welsh schools shut in March. The dilution of local authority obligations did not kick in until 1 May, and that is both the dilution of that duty to deliver provision and the relaxation of timeframes around EHC plan processes. It is interesting that it came in at that point when there was a period of time when local authorities should have been delivering absolutely what was in children and young people’s EHC plans.
It is important to remember that provision in EHC plans is not just about provision delivered by schools and within schools. It is also about those other agencies also delivering elements of provision, including health professionals and social care professionals, which are part of the same local authority. It is important to recognise that this is not an issue about schools having a dilution of responsibility; it is an issue around local authorities.
Charlotte Ramsden: I totally accept that that is the case. It does not change the fact that the ability of both local authorities and those partners to deliver in a state of lockdown was obviously changed. As a very practical example, schools were open but whether they could safely cater for all children or the parents of those children wished them to be there were very local discussions. On the risk assessments, I totally agree. In the way risk assessments were done, some were school-led and some were local authority-led but the discussion was always intended to be there jointly and with parents as well.
In terms of the wider support, of course we went from being able to do face-to-face support, particularly face-to-face short-break support, to having to do things virtually other than in risk-assessed situations where we may have gone in in PPE to do something. We could not deliver the sort of services that we would normally deliver in a way that was permissible under the lockdown arrangements.
Huge amounts of really creative and flexible work has been done to mitigate that, so the digital resources that have been available, the online contact that has been happening with families and the wraparound support as far as we have been able to bring that in. A huge amount has happened to tackle that.
As had been said, as lockdown has eased, more face-to-face support is now going back in. We are looking at different creative solutions for short breaks and, over time, more children with education, health and care plans have gone back to school. We would have wanted to see more, but more have gone back to school.
Q83 Elliot Colburn: Could I pick up on the point you made about the inevitability of the variability of interpretation? I do not necessarily disagree, but would you accept that there is a level of concern in just how wide that variation was? We are not talking here about a very minor difference between boroughs or within boroughs; we are talking about a difference ranging from continuing to provide 100% of the services within plans to nothing within the plan. Is that also something that you would consider to be inevitable?
Charlotte Ramsden: It is very difficult to say, because I do not have all the individual circumstances of those different places. It seems extreme. I have not seen any evidence to say that that has been the case but, if that evidence exists, that would seem to be extreme. Yes, I cannot really comment any further on that. It would seem unusual.
Q84 Elliot Colburn: As we are easing lockdown measures now, the national notice is expiring at the end of July. Local authorities will be expected to take back the provision as it was previously. Charlotte, how prepared do you feel local authorities are to deal with that notice expiration?
Charlotte Ramsden: We are as prepared as we can be. We are used to delivering against those expectations. That has been our job ever since the Act was enacted. The challenges of doing it will depend on certain factors and, as yet, we do not quite know how things will play out. There is the intention for all children to return to school in September. As for how that relates to test and trace arrangements, local outbreaks, the need for local lockdown, the need to close schools to outbreaks, we do not yet know how that will play out.
Likewise, we are gradually returning to a more face-to-face mixed model, and it is a very mixed model at the moment. We are not back in offices. We are doing more face-to-face visits to families, but clearly there are all sorts of discussions and assessments being done there around what is safe and appropriate linked to Covid risk.
At this stage, it is really hard to say everything can revert to normal from the end of July. From our perspective, there are real risks that, during further spikes in Covid, whether they be in local areas or across the entire country, we will be back to the position we have been in during the height of lockdown and, despite the relaxations being ended, we will struggle to fulfil all those requirements in the ways set out.
That does not mean we are not doing our utmost to prepare for that to be the case. We are learning all the time the ability to deliver more things virtually than we ever thought was possible. Some things that we could not do virtually, even at the beginning of this pandemic, we can do virtually now. Some things that were delayed during that early time, when we simply did not have the virtual systems, either the technology or the equipment, in place in order to do certain things, we can do now. We are confident that the impact would be less negative than it was at the very beginning of lockdown. We will be doing our utmost to comply.
Q85 Elliot Colburn: That is fantastic. Picking up on that point, is there anything further from central Government that would help make that transition easier?
Charlotte Ramsden: It is a recognition that there will need to be flexibility according to what happens next with this pandemic. We are already seeing, in the grading of public health concerns for different local authorities or areas within local authorities, as those things spike, parents choosing to take their children out of school. We need to be ready to manage all those things and support families on that hybrid flexible model. For children with SEN support or at education, health and care plan threshold, we need to be ready to deliver a hybrid model or a home-based model according to what is happening with the pandemic. That is really important for Government to recognise.
There are also some risks that we are still working through of everybody returning to school. There are anxieties depending on the make-up of school buildings and that capacity to meet all needs safely, particularly for children who struggle with social distancing or where numbers may be large. In our secondary schools, for example, the guidance is working in very large bubbles but members of staff will work across those bubbles. There are assumptions about how that will work for children who receive support in school, which is a number of those with education, health and care plans and some at SEN support level as well. Who can come into school and who cannot, and in what circumstances? All those details are being worked through.
There is a lot still to prepare for, which we are working on at the moment, about the detail behind the intention to the deliver the best support that we can to children with SEND from September.
Q86 Elliot Colburn: Thanks for that, Charlotte. I know that was more aimed to towards you but, Ali, was there anything that you wanted to add into that from your perspective?
Ali Fiddy: There seems to be quite a lot of focus on the need for individuals to come in and deliver provision on a face-to-face basis. Actually, that is not necessary. We have all learned, in the past few months, that so much can be delivered remotely. It has been particularly disappointing, given that a lot of special educational provision could be adapted and delivered remotely, whether that involves a child being in school and the provision being delivered remotely with the teaching staff around that child or, indeed, the child being at home and accessing it through a system such as we are speaking together on now. We need to be realistic about the fact that that is possible and achievable.
Charlotte Ramsden: I totally agree with that. That is what I was referring to in terms of the learning that has happened since this started. This virtual world that has been created by the ability to deliver services virtually is growing all the time. Things like speech and language can now be delivered virtually.
We are getting feedback from children at SEN support level who are having support at home virtually, are loving it and find it better than when they got it in school. That is why we are more hopeful than we thought we would have been three months ago about how we can do this going forward for September.
Q87 Elliot Colburn: I am conscious of time, so I will quickly rattle through my last points. In relation to a possible extension of the regulations that have modified the time limits to deliver EHC plans, considering where we are now with the lockdown, would you consider there to be any justifiable reasons as to why that could continue to be extended? I will start with Ali, as she is shaking her head.
Ali Fiddy: No, absolutely not. It is really important to remember that what we have got here is a backlog of a massive proportion of children and young people who have been identified as needing additional support who, because of the temporary relaxation of the timeframes, are stuck in limbo waiting for their needs to be assessed, for a plan to be produced or for assessments to be undertaken. We have not seen the level of creativity we would have hoped to see around EHC needs assessments being undertaken during this period.
Obviously, there is going to be a backlog. The temporary change will be removed on 25 September. There needs to be a really clear set of priorities for dealing with that backlog because there will also continue to be the normal number of children and young people coming through the system.
There will be a whole new tranche of annual reviews that need to be undertaken. We would like to see some level of scrutiny from the DfE and a level of reporting from local authorities about where they are at with particularly dealing with a backlog of decisions and processes that have been held up under those regulations.
I gave evidence to the Education Committee a couple of weeks ago that we were seeing a widespread misinterpretation and misapplication of those temporary regulations as a way of avoiding making decisions that either were not covered or, indeed, would then trigger a right of appeal to tribunal. There is going to be an impact on tribunal appeals. We have not seen that happening yet but it is inevitable that that will happen.
Q88 Elliot Colburn: On the point of backlogs, could you expand a little more on what exactly you think needs to happen for local authorities to manage that backlog? Perhaps I could then bring you in, Charlotte, for your perspective on the concern about the backlog and what you think needs to happen.
Ali Fiddy: I do not think I can talk about how local authorities need to manage that. That is an appropriate question for Charlotte. The reality is that there are children waiting to have their needs met. That needs to be a priority. There will also be different priorities within that group and I think there needs to be very clear guidance from Government and very clear scrutiny of what is happening on the ground.
Charlotte Ramsden: It is inevitable that there is a backlog. The fact that the timescale has been relaxed has been welcome and, again, is a reflection of the reality. There will be a real pressure if that relaxation ends in terms of timeliness and quality. Clearly, nobody wants to see a child languishing because their assessment is delayed and therefore the plan is delayed. There will be a real balance between how much we just get decisions made on the basis of the best we can pull together and how much we really drive the continuation of the quality because the child’s needs are being met despite the fact that that assessment is not complete.
There will be some balancing to do in managing the backlog around prioritising those children whose needs are clearly not being met right now, to get those completed, and those where we can wait a bit longer because their needs are being well met, despite the fact that there is further work to do on the next steps.
We have been working very hard to make sure that all children have an appropriate place for September. Regardless of what has happened around the delay in assessments, that work has been going on to make sure that children know where they will go for September and to support them in that, even if there is still further work to do. The backlog of assessments inevitably has built up because, as we have said before, we have struggled, to varying levels, with the availability of professionals to work together to develop the assessment and complete it, and work with the families as well. Some people have done that better than others, as we know. Going back to the point we made before, the ability to do that virtually is now much improved so hopefully will not be such an issue going forward.
Alongside the backlog, there are the ones who have not been identified during the summer term. There is often a spike in identification of children who need assessment during the summer term. Some of those will not have been identified because they would have been at SEN support level and therefore have not been in school. Those will come out as children go back in September. We do not yet know the impact that Covid has had and whether that will have enhanced further the number of children who may need to be assessed because of the impact on their behaviour and the distress that has been caused to them during Covid.
We anticipate a huge pressure for September. We do not suddenly have a lot of extra people to do that work. We can refocus and move around the resources we have. That has all been discussed, but we do not suddenly have an influx of additional resources that mean we can clear the backlog more quickly than we would otherwise have done. All we can do is reprioritise what we do. Completing assessments and making sure that children have appropriate plans will be absolutely at the top of that list.
We know we will also have a pressure around the need for reviews. Some children who have plans will be seeking early reviews, because of the impact of what has been happening over the last few months. That will have had some detrimental impact on them, which will mean we need to review their needs in order to meet them better. It is going to be a really complicated and challenging picture. While we recognise that that relaxation of timescales is due to end, from an ADCS perspective, we would welcome that being extended further, subject to some strict criteria that we would be accountable for.
Q89 Kate Osborne: My questions fit in quite nicely from what you were saying there, Charlotte. They focus specifically on the reopening of schools in September, adequacy of guidance and support for SEND. Some children and young people with SEND have struggled emotionally and mentally during lockdown. Some may be anxious about returning to school and some may find the change to their routine and the transition to school very difficult. What good practice should be implemented in schools to help children with SEND settle back into school after such a long absence?
Charlotte Ramsden: We have been working on that a lot, as you would expect. The first thing is around clear explanations of how school is going to work. That needs to be nuanced according to the needs of individual children. There is an age element there but, for those with SEND, we need to make sure that is delivered in an understandable form. There are lots of video clips and storytelling things being put out and obviously discussions with parents. An understanding of what school will look like so they know what they are going back to is really critical.
When children do go back in, it is about making sure that the support available for them is really flexible and recognising that all children will be struggling with return in some way. Some have loved being off, so coming back is really hard and the anxieties about that are going to be enormous, as they always are at the beginning of a school term for every child. There is always that bit of, “What is school going to be like this time? What is my new teacher like?” Magnify that for not having been in school since March for many of those children, and their additional vulnerabilities and needs. That is really significant.
We are working on support that is flexible, low key, emotionally intelligent and trauma-informed. We are providing training materials to schools, so that they are aware of how to respond to the different needs that children have as they come through the door.
Out of that, we will be identifying those children who need more than just mainstream emotional support to reengage, reconnect and work in school in a way that may be different to how it was last year. We are preparing behind the scenes, in partnership with our CAMHS colleagues and mental health support in schools programmes, for what additional support we anticipate some of those children will need, but we do not want to over-pathologise the start of the school term.
Of course, we then have the education curriculum, because children have missed a lot of their education, despite the fact that education resources have been going into children’s homes and virtual teaching has been happening. Schools are really gearing up for being very flexible at the start of that, understanding where children are at and moving forward, not trying to go backwards and say, “Well, they have missed this, this and this”, but trying to meet them where they are at educationally and to move them forward.
From an SEND perspective, the SENCO is obviously going to be absolutely critical to that process, in terms of SEN support and education, health and care plans, in guiding children, schoolteachers and parents around how to do that in a way that is individual for support for those individual children.
The other thing that is really important is the role of the school in its place. Increasingly, we have early help resources that are supporting schools. That may be parenting support, support through health colleagues or different forms of intervention around emotional health and wellbeing. We need to make sure that those are fully wrapped around schools at the beginning of term so that we are all geared up to that same aim, which is to reintegrate children in a way that works for them and connect them up with the support they need so that they can then start to achieve.
I think there has been an announcement today on the catch-up funding for children, although I have not read it, but the allocations per child have come out today. There is a question to be checked, for those who are at SEN support level or have an education, health and care plan in the mainstream, on what their allocation is, because there is a mainstream allocation and a special school allocation. I am not quite clear yet and have not looked at what that is going to mean. That funding will then need to be allocated wisely to support education progress.
Ali Fiddy: There needs to be a proper programme of reintegration for each individual child, which should involve parents as well as the child and should not just be imposed on them. I agree with Charlotte that the reintegration of all children into a formal learning environment is going to be a real challenge.
If you add to that any kind of additional needs, that is going to be more challenging and there will be particular groups of children and individual children for whom that will be even more of a challenge. We are very concerned that we are going to see a big spike in exclusions. Greater scrutiny of the use of exclusion powers within schools during this period is absolutely necessary.
Q90 Kate Osborne: Do you think that some children and young people with SEND should be allowed to continue their education at home for a period of time? If so, how should they be supported? How do you feel about children and young people with SEND having a phased return to school?
Ali Fiddy: We certainly have received an increase in inquiries from families who say, “Actually, my child has coped much better at home with that environment and with not having to go in and deal with the challenges they experience within a formal school environment”. We have been dealing with more inquiries around that in terms of what can be done for children and young people with the EHC plans who have had that experience.
There is no one-size-fits-all approach here. It needs to be about children’s individual needs. It may require a phased reintegration but, equally, we do not want to see that being exploited and abused, and children not being allowed into school on a full‑time basis because their behaviour is a bit challenging. We have seen issues coming up around informal exclusions and off-rolling. We have to be cautious around that, but this has to be an approach that is taken that involves all concerned and not a one-size-fits-all.
Charlotte Ramsden: I absolutely support that. There will be some flexible returns for some of those most vulnerable children. To suddenly say one day, “You have been at home for an indefinite length of time”, and the next, “You are back in school five days a week” is setting some children up to fail. The risk is that we are too flexible and children never return in full, so we need to get a good balance between a purposeful flexible plan for those few who need it, but still be very clear that the norm is to return to school full time.
As we said previously, we need to build in flexible hybrid models because we do not know where this is going to take us next, and we do not know at what point we may be asking a bubble to go home because we need to do that for Covid reasons, or a school to close, again for Covid reasons. We need to build in those flexible approaches, and that would be done alongside, “What are we doing for each individual child and what is their individual integration plan?”
Out of them all, Ali is absolutely right: the group that are most vulnerable in all this are those whose behaviour is challenging. For those whose behaviour is challenging, when they are settled, it is going to be very, very hard for everybody to integrate them successfully back in and for everybody to feel that we have working arrangements that work for them, for the other children they are with and for the staff.
There is a lot of anxiety about managing that currently and a lot of work going on with health professionals around how we do that well, but Ali is absolutely right about watching how that works and watching the risk of exclusions. We are going to need to keep a very close eye on that.
Q91 Kate Osborne: On 2 July, the Government published guidance on the full reopening of schools in September. Do you feel that the guidance provides enough information and support for teaching professionals to bring children and young people with SEND back to school in September? What additional guidance would you have liked to see in there?
Charlotte Ramsden: Similar to previously, the guidance was helpful and very clearly provided the principles, the expectation of all children back in school and the recognition that within that there would need to be some hybrid model working. There were two lots of guidance. One was for the special schools.
In all the discussions I have been involved in, people were very much supportive of that guidance and felt it to be flexible and helpful. Within the mainstream guidance, we would have liked to see a bit more about children at SEN support and education, health and care plan thresholds, the use of graduated support, how that could work and the management of the complexities that that could raise if we are still trying to work in the kind of arrangements that we are around bubbles of children.
We spoke before about the risks within that secondary guidance about crossing bubbles. That is for curriculum purposes, but we normally have lots of individuals going into school to offer different types of support, constructive activities and opportunities. We are working through what we can and cannot do, and what can be done virtually because it can no longer be done face to face, et cetera. More guidance about the involvement of virtual support would be welcomed.
The other thing that probably is not recognised to the extent that we would want it to be is how time-consuming the new requirements are: the expectation that, if someone has been on public transport, they will have worn a mask and then they need to take that mask off, wash their hands, et cetera. Along with flexible lunch times and possibly even flexible start and end times for the day, that is a lot of complexity to manage. Any further detail on that would be welcome.
The relationship with home-to-school transport, which is obviously particularly pertinent for children who are entitled to it with education, health and care plans, remains a complexity that is not fully resolved. On the connection with that wraparound support and how to do that, the guidance came out, which is great, but we anticipate that some things will have moved on by the end of August before children are due back in school.
For example, the guidance about wearing masks in shops has come out since the guidance was issued. Are there any implications about that for schools that we need to consider? There are further details that we would expect to be provided before we get to schools actually reopening.
Ali Fiddy: From our perspective, we are concerned about whether the guidance is clear enough about the expectations from parents, children and young people’s perspectives. The focus in those guidance documents is largely on avoiding the transmission of Covid-19 and ensuring that curriculum requirements are met. There is more in the special school guidance about children and young people with EHC plans, but the guidance for mainstream schools is virtually silent on children and young people with SEND and particularly those with EHC plans.
I am astounded by that. It very clearly sends a message that mainstream schools do not need to do anything differently for children and young people with SEND. It goes against that idea of inclusion of children and young people with SEND within mainstream settings, which we know is a fundamental problem. That is incredibly disappointing in terms of Government guidance.
There is a section in the special school guidance that talks about the use of, perhaps, risk assessments to look at the additional support that children and young people with SEND may need as they are going back into school. That is not replicated in the mainstream school guidance. We need a dedicated set of guidance for children and young people with SEND relating to both those on SEN support and those with EHC plans.
It is very interesting that there is nothing within that guidance about a requirement for measures to be put in place to ensure that any of that lost provision is made up. It is very, very disappointing and very, very worrying for children and young people with SEND and their families.
The effect of these dilutions of the legal obligations during the period of lockdown is that the children and young people most in need of support have been the least supported and the most disadvantaged during lockdown. It looks as if they are going to be the least supported and the most disadvantaged when they go back to school.
Charlotte Ramsden: Ali has expressed, much more strongly than I did, that shared concern about the difference between the guidance for those who are in special school and the guidance for those who have those additional needs but remain in mainstream. Schools are grappling with managing that. Additional Government guidance on that would be welcome.
We know they were keen to provide that overarching umbrella of guidance within which local work would then be done, but we want things to be as consistent as possible, because children often live in one authority and go to school in another or have siblings in different places. We want to make sure that we are as consistent as we can be.
Within school responses, once we have some understanding of where children are at when they come back into school, the differential support on educational needs will need to be really clear, so that that catch-up funding can absolutely be targeted where it is most needed. The children who particularly lost out need to be the ones in receipt of that funding. Again, the most vulnerable groups within all that are those SEN support and education, health and care plan groups that are going to be done in that mainstream way. Schools will not want to do that, but the guidance, as we have both said, does not recognise that fully as yet.
Q92 Kate Osborne: Charlotte, you have led me nicely into my last question. We know that, before the coronavirus pandemic, schools and local authorities were facing a shortfall for SEND and reaching a crisis point. Although the Government has announced a £1 billion catch-up premium for schools, there is no specific or ring-fenced funding for SEND. Do you agree with Philippa Stobbs of the Council for Disabled Children that this could widen the gap between those children and young people with and without SEND?
Charlotte Ramsden: Yes, absolutely. From just a very quick look at the numbers that have come out on the catch-up funding, it looks to be £80 a child for mainstream and £240 for special schools, but there is nothing about those children with education, health and care plans in mainstream. Do they get the £240 or the £80? I have not looked at the detail yet, so I need to follow that through, but the budget gap is very, very significant. Without that being addressed, we will continue to struggle to meet those children’s needs well.
I go back to the Isos report that was commissioned by the Local Government Association, which I referenced right at the beginning. The funding gap in supporting children well is massive. It is not just the funding gap from the high needs block for dedicated schools grant; it is also the funding from within social care in terms of that wraparound support because, where children need support in school, they or their families also need support at home. There is then the relationship with health and making sure that children’s health budgets are prioritised as well as adult health budgets, particularly in these Covid times.
There are some heartening messages coming out around that about the recognition of children’s mental health needs, the need to invest well in those and the recognition that that is going to be a real priority as schools go back. Some of the information coming out suggests that need is understood, but that has not yet come with resources that are going to help us do that.
Q93 Kate Osborne: Ali, I was not going to ask you about funding in particular but are there any comments that you want to make?
Ali Fiddy: The joint ministerial letter published yesterday suggested that some of that catch-up premium could be used for specific support, such as extra teaching capacity, speech and language therapists, educational psychologists and those sorts of things, which would be focused on supporting children and young people with SEND. The risk is that this is exactly the same problem we see with SEN support, where that funding is not ring‑fenced and it does not get used in the place that it is needed the most. That is the risk associated with the lack of ring‑fencing.
Chair: Can I thank both witnesses for having participated this afternoon? Your evidence has been incredibly valuable. If there is anything you would like to add in writing, please do so after today’s Committee. That concludes the evidence session.