Written evidence submitted by Better Communication CIC (SFC0073)

1. Better Communication CIC is a not-for-profit community interest company established by Marie Gascoigne in 2011 in response to the ongoing demand for support from children’s services across health and education in relation to supporting children and young people’s speech, language and communication needs (SLCN).  Since then, Better Communication CIC has supported over 30 local area systems to understand the needs of their population, develop specifications for joint commissioning, facilitate transformation of local provision for children and young people and develop tools and systems to support integrated services and impact measurement.  Marie Gascoigne as been commissioned by the Royal College of Speech and Language Therapists (RCSLT), the DfE via the Communication Trust and Scottish Government to provide guidance around joint commissioning for children and young people with SEND or additional needs from the perspective of speech, language and communication needs but the resulting frameworks and transformational processes are equally applicable across the spectrum of SEND. For more information a summary can be accessed at https://www.thebalancedsystem.org/downloads/balanced-system-information-for-commissioners/
2. The underpinning methodology and philosophy for the work of Better Communication CIC is the Balanced System.  The Balanced System was developed in response to the ongoing challenge of meeting the needs of children and young people who require support to develop skills and maximise potential, from a range of practitioners across health, education and social care.  The framework has its origins in supporting speech, language and communication needs but is increasingly used in iterative versions to consider other therapies, SEND, and more recently some adult populations.  The Balanced System Scheme for Schools and Settings is an accredited improvement programme for schools and settings developed in partnership with charities NAPLIC and Afasic which facilitates schools and settings to develop their provision for speech language and communication for all children including those with SLCN.  This has also been piloted as a SEND improvement scheme. The Balanced System High Level Outcomes Framework was included as a model of good practice in the Public Health England (2021) “Best start in speech, language and communication: Guidance to support local commissioners and service leads”.
3. The evidence we wish to present to the enquiry is based on the learning from the complex system transformation projects we are commissioned to support by Integrated Care Boards and Local Authority partnerships across England (and the UK in their relevant structures).  Better Communication CIC currently is engaged in supporting cross agency transformation including advising on joint commissioning processes to meet the needs of children and young people including those with SEND in projects across Greater Manchester, Lancashire and South Cumbria, Southend, Essex and Thurrock, Birmingham, Hereford and Worcestershire, Devon, Torbay and Plymouth, Dorset, Christchurch, Bournemouth and Poole, and Kent. 
4. The needs analysis process in all of these areas has involved capture of not only quantitative data regarding the population, demographic, SEND, and attainment data along with workforce and caseload information for the therapy areas under consideration, but also qualitative analysis to a common outcomes framework of the provision for children and young people from all elements of the workforce (including the ordinarily provision in schools and settings) as well as the specific contributions and activities of the therapy services. This combination of understanding need and the current response to that need across the integrated system provides a specific picture and rich dataset.  The stakeholder engagement element of these needs analyses also captures the experience of families and where possible children and young people.
5. The transformation process then requires a tailored response to the local situation and it is from these experiences that we wish to draw the committee’s attention to some recurring themes which relate directly to the three areas identified in the call for evidence.
6. The committee is interested in evidence pertaining to,

• Performance of the system
• The overall picture on the support available and outcomes achieved for those with SEN; and
• Government action to create a sustainable SEN system and restore confidence.

7. A key element of the Balanced System is the request that every activity or intervention or element of provision described by any part of the system is able to also provide evidence of impact.  This is rarely achieved. 

Performance of the system

8. Key point 1: The vast majority of local area systems focus on metrics that are input driven, waiting list numbers, number of referrals to specialist services, activity data such as ‘face to face’ contacts, specified minutes and hours in Education, Health and Care Plans. 
9. Hardly any have measures of impact included on monitoring dashboards or indeed are the focus of those leading service delivery.  Unless impact measurement becomes a key metric, the system will continue to be driven by requirements of activity, much of which has no evidence of effectiveness.  The performance of the system is therefore driven not by need but by processes which require a culture shift towards impact and away from inputs.
10. Key point 2: There is an assumption that the ‘specialist’ workforce should focus on ‘specialist’ interventions to support children and young people with SEND.
11. The performance of the system is impaired by a perverse incentive towards increasing and potentially unnecessary demand for statutory assessment because the continuum of support is not readily available at SEN Support or as part of the Ordinarily Available Provision in an area.
12. There are two key diagrams that encapsulate this issue and are more effective in conveying the complexity of this issue.  The concept of therapy services needing to work at universal, targeted and specialist levels was first introduced in the UK therapy context in the 2006 position paper published by the RCSLT[1].  Figures 1 illustrates the need for the understanding that in order to be impactful in a system the specialist workforce may need to be actively engaged in all of the offer for children and young people.  Equally, it shows that because a child or young person has an EHCP, it is not a given that the most impactful support will be at a specialist level, delivered by a specialist.  The National Audit Office report references situations where the need for access to ‘health’ workforce is driving the EHC process. 

Figure 1: Showing the need for specialist workforce and wider workforce to be active across all of universal, targeted and specialist levels of offer and for the whole range of children and young people[2]

13. This leads to Figure 2, first used in the context of SLCN in 2021 but adapted to consider all therapy areas, which aims to illustrate the ‘vicious cycle’ that is borne out of not prioritising the development of a continuum of support to meet outcomes at universal, targeted and specialist levels, delivered by the whole children and young peoples’ workforce but critically acknowledging that the impact of a specialist in the workforce such as a speech and language therapist or occupational therapist having commissioned time to develop, enhance and maintain the universal and targeted provision is potentially more impactful that being expected to only delivered ‘specialist’ interventions.

Figure 2: Illustrating the 'vicious cycle' of not focusing on the development of the whole system response[3]

The overall picture on the support available and outcomes achieved for those with SEN

14. As outlined above, Better Communication CIC and the Balanced System tools have a rich dataset regarding the support available and the outcomes achieved for those with SEN.  If the committee would find it helpful to have a more granular export of data, appropriately anonymised, we would be happy to provide more detail with more time.
15. Key point 3: The mapping of provision across many local area systems reveals significant differences in the ‘offer’ and little evidence of consistent outcome measures or measures of impact

Figure 3, illustrates the variance in provision mapped against the Balanced System Outcomes Framework in an area where several Local Authority systems were part of the overall project.

16. Figure 3: Showing the variation between three areas in one overall project in terms of the proportion of support for CYP with SEN across universal, targeted and specialist support

Government action to create a sustainable SEN system and restore confidence

17. Finally, the committee invites evidence around Government action to create a sustainable SEN system and restore confidence.
18. For the purposes of brevity the following suggestions are presented in bullet point format:

• Refocus the local system partnerships between ICBs and LAs on the ambition of joint commissioning for all therapy support for children and young people including children and young people with SEN
• Require impact measurement towards jointly agreed functional and meaningful outcomes for children and young people and their families to be incorporated into ‘business as usual’ and the measurement of jointly commissioned service provision
• A culture shift is necessary away from the ‘health’ vs ‘education’ vs ‘social care’ portfolios so that a population led approach to understanding need and delivering provision becomes the norm
• A recognition that, as stated in the opening paragraph of the National Audit Office report, that SEND is a relative descriptor and that in an ideal world the ‘ordinarily available provision’ should a) include therapy contributions and b) result in less need for families to have no alternative other than pursue an Education, Health and Care Plan for their child or young persons’ needs to be met.

November 2024