REVIEW OF THERAPY SERVICES IN LEWISHAM
DR. KITTY MOHAN
PUBLIC HEALTH LEWISHAM
JUNE 2012
CONTENTS
1
1. SUMMARY
3
2. INTRODUCTION
4
2.1 Aim
4
2.2 Methods
4
3. BACKGROUND
5
3.1 Disability and Special Educational Needs (SEN)
5
3.2 The prevalence of disability in children
6
3.3 Key policy documents
9
4. THE LEWISHAM PROFILE
14
4.1 Population profile
14
4.2 Population projections
15
4.3 Prevalence of disability in Lewisham
16
4.4 Prevalence of children with therapy needs in Lewisham
18
5. THERAPY SERVICES FOR CHILDREN AND YOUNG PEOPLE IN LEWISHAM
20
5.1 Speech & Language Therapy (SLT)
20
5.2 Occupational Therapy (OT)
24
5.3 Physiotherapy
27
5.4 Joint working
29
5.4.1 Joint working between therapies
29
5.4.2 Joint working with other agencies and services
30
6. CONCLUSIONS
31
7. RECOMMENDATIONS
32
8. REFERENCES
34
APPENDICES
APPENDIX 1: Eligibility criteria for Family Fund Trust (FFT) financial assistance
36
APPENDIX 2: Prevalence model for disability in Lewisham
37
APPENDIX 3: List of stakeholders interviewed and main questions asked.
39
2
1. SUMMARY
This Healthcare Needs Assessment (HCNA) was conducted at the request of Commissioners of the
Children’s therapy services in Lewisham. This builds on the Commissioning Review conducted in
2009-10 and from discussions with the Community Therapy leads.
This comprehensive review of therapy services for children in Lewisham has revealed that there are
some important areas that the Partnership will need to address in order for a sustainable service and
the best possible care to be available for children and young people in Lewisham:

Therapy team leaders must urgently develop and pilot tools for the identification of children
with high clinical need across the under 5, mainstream school and special school pathways.
As part of this tool, the term ‘high clinical need’ must be defined separately for the speech
and language, occupational therapy and physiotherapy services (Recommendation 1, 7 and
10)

The level of need for a designated autism pathway for occupational therapy needs to be
described. This should take into account the impact of the OT service on the effectiveness of
the other therapists for children with ASD. (Recommendation 8).

The integration of Local Authority children and young people occupational therapists into
the community health team must be undertaken in order to achieve a more joined up
effective service and avoid duplication of resources (Recommendation 9).

Robust education and training programme needed in schools to train healthcare and
educational professionals, including nursery staff and health visitors and how to best
support children with therapy needs (Recommendation 2).

Ways in which therapists work together to optimise the therapy goals of children, for
example through a joint initial assessment clinic, should be considered (Recommendation 6,
15 and 16).
A comprehensive list of all recommendations made in this report is included in Section 7.
3
2. INTRODUCTION
This Healthcare Needs Assessment (HCNA) was conducted at the request of Commissioners of
the Children’s therapy services in Lewisham. This builds on the Commissioning Review
conducted in 2009-10 and from discussions with the Community Therapy leads.
2.1 AIM
2.2 METHODS
Methods used include a review of published literature and key policy documents related to
therapy services, and semi-structured qualitative interviews with key-stakeholders.
3. BACKGROUND
3.1 Disability and Special Educational Needs (SEN)
4
The Equality Act 2010 defines a person with a disability as someone who has a physical or mental
impairment that has a substantial and long-term effect on his or her ability to carry out normal dayto-day activities1. The definition of disability encompasses a broad range of impairments, including
the autistic spectrum, Tourette’s syndrome and communication difficulties. It has been suggested
that between six and seven per cent of children are disabled, and three-quarters of these children
also have special educational needs (SEN)1.
There is wide variation in the proportion of pupils identified with SEN at a local authority level
ranging from 11.9% to 33.5%. The term SEN encompasses several established categories: specific
learning difficulty, moderate learning difficulty, severe learning difficulty, profound and multiple
learning difficulty, behavioural, emotional and social difficulties, speech, language and
communications needs, hearing impairment, visual impairment, multi-sensory impairment, physical
disability and autistic spectrum disorder.
School-aged children are defined as having SEN if they have a significantly greater difficulty in
learning than the majority of children of their age which calls for additional or different educational
provision to be made for them2. In January 2010, it was estimated that 21% of the school population
had SEN
There are currently three levels of intervention for pupils with SEN in England2:
• School Action – this is where different or additional techniques are used by the teacher or the
school Special Educational Needs Coordinator (SENCO) to help children learn. In January 2010, it was
estimated that 11.4% per cent of the school population were of School Action level, approximately
916,000 pupils;
• School Action Plus – this is where the school consults specialists and requests help from external
services in order to meet the needs of a child. In January 2010, 6.2% of the school population were
at School Action Plus level, approximately 496,000 pupils; and
• Statement – this is where a child requires support beyond that which the school can provide and
the local authority arranges appropriate provision. In January 2010, 2.7 per cent of the school
population or 221,000 pupils had a statement of SEN.
5
Children within the same category of SEN differ in the extent of their individual difficulties and in the
type of provision they need. Autism, or an autistic spectrum disorder, for example, covers a broad
spectrum: children with autism may require support with communication, social understanding and
thinking and behaving flexibly, and may, to a greater or lesser extent, require support to carry out
basic tasks such as eating, drinking, washing, dressing and going to the toilet.
3.2
The prevalence of disability in children
Data regarding the prevalence of disability in children is extremely sparse despite this it being widely
accepted that this information is needed to plan services for these children. The National Service
Framework for Children, published by the Department of Health in 2004 stated that there should be
“a locally based multi-agency database containing core data on disabled children, based on shared
and agreed definitions”, and that this data should be used to “monitor take-up of services against
what is known about the local population…and for planning/evaluation of services”3. However, a
report by the Audit Commission in 2003, investigating availability of services for disabled children
found that neither commissioners, nor providers, had a comprehensive understanding of the
numbers of local disabled children, which, they concluded, made it impossible to plan services
effectively4.
Estimates of the prevalence of disability are highly sensitive to the measures used5. The most recent
national survey to specifically examine the prevalence of disability in children in England was
conducted by the Office of Populations Censuses and Surveys (OPCS) between 1985 and 19886. This
survey showed that the overall prevalence of disability in children in England was 3.2% of the
population aged less than 16 years, but that only 36% of disabled children (5-15) had a single
disability, the majority having two or more disabilities.
The OPCS survey collected comprehensive data on around 2,500 children with disabilities, who were
identified following an initial screening process involving 100,000 households. The main criticism of
the OPCS survey was that it used a medical definition of disability, which focused on the individual
and their impairments, instead of examining the broader, social perspective on disability.
In 2000, Gordon et al undertook a re-analysis of the OPCS survey7, in part to address some of the
above criticisms. Figure 3.1, shows the estimated prevalence of ‘limitations’ in children under 16,
based on sources from the Gordon et al reanalysis. They found that the estimated prevalence of
‘limitations’ varied, depending on the data source, ranging from 2.6% of children, (estimated by the
1991 Census), to 16%, (estimated by the Isle of Wight study).
6
Figure 3.1: Estimates of the Prevalence of Limitations in Children under 16 (taken from Gordon et al, 2000)7
Source
Type of Limitation
Percentage of Children with Limitation
Rutter et al., 1970 (Isle of Wight
Study in 1964 of 9-11 year olds)
Handicapped
16
Weale and Bradshaw, 1980
(based on the 1974 GHS)
Severe and moderate
handicap
3
Court, 1976
Severely
and
moderately
handicapped (excluding
psychiatric handicaps)
9
Survey
Limiting
illness
6
OPCS disability surveys 1985
and 1988
Disabled
1991 Census
Limiting
illness
1995 Health Survey for England
(10-15 yr olds) (Prescott-Clarke
and Primatesta, 1997)
Disabled (locomotion,
personal care, seeing,
hearing
and
communication,
but
excluding continence)
General Household
(OPCS, 1985)
long-term
3
long-term
2.6
5
In 2004 a report by the Office of National Statistics (ONS) used data from the General Household
Survey, (GHS), and the Family Fund’s Trust (FFT) register of applicants to estimate the prevalence of
disability in 0-19 year olds in the UK8. This report did not distinguish between psychiatric, learning
and physical disability.
The GHS is an annual survey, first conducted in 1971. In this survey disabilities are self-reported and
based on the assessment of the respondent. A judgement was made by the authors of the report
that most longstanding illnesses reported in the GHS were mild, and, therefore, for the purposes of
this report, self-reported ‘longstanding illness/disability’ in the GHS was taken to represent ‘mild
disability’.
The FFT is a fund which gives financial assistance to families with severely disabled children aged 16
and under in private households. The number of children on the FFT register of applicants was
taken, by the ONS, as a proxy for the prevalence of severe disability. However, this fund is meanstested, with only those families with an annual income less than £20,300 and savings less than
£8000 able to apply. In addition to the means-tested component, in order to be eligible for FFT
assistance, the disability criteria for ‘severely disabled children’ outlined in Appendix 1 must be met.
7
Assistance was only available for children under 16 in private households, whose families are aware
of this trust and choose to apply for funding. Therefore, this is likely to grossly underestimate the
prevalence of children with severe disabilities, although it is still considered one of the most reliable
sources of information of the number of children with severe disabilities in the UK.
The study found that the prevalence of children with ‘mild disabilities’ (longstanding illness or
disability) remained stable between 1990 and 2000, with 17% of the 0-19 year old population
reporting a mild disability in 1990 and 18% in 2000. There was a very slight increase in the
prevalence of severely disabled boys between 1990 and 2000, (from 7 per 10,000 population to 11
per 10,000 population), while the rate for girls remained constant over this period, (5 per 10,000
population). The study also demonstrated striking changes in the prevalence of conditions such as
autism or behavioural disorder which rose from 4% in 1990, to 25% in 2000. Whilst this increase
may reflect in part a broadening of the diagnostic criteria leading to a greater rate of diagnosis, the
extent of this increase would indicate that a genuine increase in these conditions is likely.
There were a number of significant limitations in to this study. The use of the FFT database
significantly underestimates the prevalence of disability as only a certain group of individuals are
eligible to apply for financial assistance. The assumption that all disabilities reported in the GHS are
‘mild’ may also produce significant inaccuracies as it is likely that any disability, irrespective of
severity, would be reported in the GHS as a ‘longstanding illness/disability’.
There are also
difficulties that arise from using self-reported disability data, for example, from different
interpretations of the questions leading to reduced reliability of the findings8.
The Family Resources Survey (FRS) is a national cross-sectional survey which collects information on
the incomes and circumstances of approximately 29000 private UK households which contain 16000
children aged 0-18 years9. The FRS uses the Disability Discrimination Act (DDA) criteria (1995 and
2005) to identify disabled people. Using DDA criteria, children with a limiting longstanding (12 month
duration or longer) illness, disability or infirmity experiencing one of more significant difficulties or
problems, including those who would have these health problems if they did not take medication,
were defined as having a disability9. In 2010, Blackburn et al, undertook further analysis of the data
collected from the FRS in 2004-2005 to report prevalence estimates of childhood disability for the
total child population. They found 7.3% of children to have a DDA-defined disability, amounting to
952,741 children nationally. When the results were stratified for different age groups, 3.7% of
children aged 0-4 years, 8.2% of children aged 5-11 years, 9.5% of children aged 12-15 years, and
8.5% of children aged 16-18 years were reported to have a DDA-defined disability10.
8
In 2009, Read et al conducted a comprehensive search and evaluation of data sources with
information on disabled children. They included 30 data sources: nine cross-sectional surveys, nine
longitudinal and panel studies, seven administrative data sets, four specific condition databases and
one other type of study. They found that all studies used different criteria or methods of obtaining
data, and all had significant and numerous limitations11.
Accurately estimating the number of children with the most severe disability at a national level, as a
proxy for those with the highest level of need is both difficult, and may be subject to variation
depending on which criteria are used. The FRS is now considered by the Department of Work and
Pensions to be its key source of information on disability. However, these figures vary widely from
the OPCS survey and ONS report, which are still widely considered to represent the most
comprehensive studies of the numbers of children with disabilities in the UK.
3.2 Key Policy Documents
Several policy documents regarding children with disabilities which have been published in the last
five years. In addition, there have been key policy documents, specific to Speech and Language
Therapy (SLT), published. These documents are summarised below:
3.2.1 The Special educational needs and disability (SEND) Green Paper (2011)2
The Special educational needs and disability green paper ‘Support and aspiration: A new approach to
special educational needs and disability’ went out to consultation in March 2011. The report seeks to
address concerns about the lack of support and choice regarding care available for families with
special educational needs.
The proposed reforms calls for:

a new approach to identifying SEN in early years settings and schools to challenge a culture
of low expectations for children with SEN and give them effective support to succeed.

a new single assessment process and ‘Education, Health and Care Plan’ by 2014 to replace
the statutory SEN assessment and statement, bringing together the support on which
children and their families rely across education, health and social care.
local authorities and other relevant stakeholders to set out the services available to support children
who are disabled or who have SEN and their families. This includes the services available for children
with low level special needs.
3.2.2 The Ofsted Special Educational Needs and Disability Review (2010)12
9
The Ofsted Special Needs and Disability Review in 2010 noted that for children with the most
obvious and severe needs who had a clear medical diagnosis, these needs are identified at an early
age, and managed effectively. However around half the schools and early years provisions visited by
Ofsted used low attainment and relatively slow progress as their principal indicators of a special
educational need. Whilst these measures may identify some kinds of disabilities and may not be
optimal to identify children with the highest therapy needs.
3.2.3 The Bercow Report (2008)13
In 2008, ‘The Bercow report: A review of services for children and young people (0-19) with speech,
language and communication needs’ outlined five key themes under which recommendations were
made:

Communication is crucial;

Early identification and intervention are essential;

A continuum of services designed around the family is needed;

Joint working is critical; and

The current system is characterised by high variability and a lack of equity.
The recommendations from the Bercow Report highlighted the importance of early identification of
children with speech, language and communication needs (SLCN) and in particular those with more
severe and complex impairment. The Report stated that a ‘more systematic approach’ is needed to
ensure identification occurs as early as possible, and appropriate provision and support is delivered
promptly, and recommended that:
‘PCTs and local authorities work together to undertake surveillance and monitoring of children and
young people to identify potential SLCN across the age range, and particularly at key transition
points’.
The report also found that approximately 7% of five year olds entering school in England, nearly
40,000 children in 2007, have significant difficulties with speech and/or language. These children are
likely to need specialist and/or targeted intervention at key points in their development.
Furthermore, it was found that approximately 1% of five year olds entering school in England, more
than 5,500 children in 2007, have the most severe and complex SLCN. They may not understand
much of what is said to them, they may have very little spoken language and they are likely to be
completely unintelligible when they start school. These children often need to use alternative and
10
augmentative means of communication. This group is likely to have a long-term need for specialist
help, in school and beyond.
3.2.4 Aiming high for disabled children: better support for families (2007)14
This report, published jointly by the Department of education and skills, and HM Treasury in 2007
marked the culmination of the Disabled children review. The recommendations identified three
priority areas to improve outcomes for disabled children:

Access and empowerment;

Responsive services and timely support; and

Improving quality and capacity.

The report recommended that ‘Primary Care Trusts PCTs and Strategic Health Authorities develop
better data on the number of disabled children and young people in need of, and receiving therapy
services to allow them to better plan, commission, and recruit to provide for their population’.
The report noted that there were 6,623 Speech and Language therapists working in the NHS in 2007,
an increase of 36 per cent since 1997. It was recommended that through the use of National Service
Frameworks, PCTs and Local Authorities should ensure that the supply of timely therapy services is
sufficient to meet the needs of children and young people who require it, based on assessed needs.
In particular, they noted cases of PCTs which have developed more effective provision of therapy
services through service redesign.
For example, in East Sussex, a drop-in monthly clinic was set up in 2002 to enable immediate access
to children and parents without an appointment. The child either receives advice and a repeat check
up at a later date or an appointment for a fuller assessment. Since 2002, waiting times have
decreased from eight months for assessment, and 12 months for treatment to commence to one
month for assessment. The number of children taken on to the caseload has decreased by 50% and
therefore the overall wait for treatment has also decreased.
3.2.5 An economic evaluation of speech and language therapy (2010)15
In 2010 research was conducted by the Matrix Evidence group to determine the economic value of
Speech and Language Therapy (SLT) for four cohorts of individuals across the United Kingdom
including children with speech and language impairment.
11
The report found that:

For every £1 invested in SLT intervention, £6.40 is generated through increased lifetime
earnings.

In total, the benefits of increased life-time earnings generated by 15 additional hours of SLT
over a period of 15 weeks for children aged six to ten years with speech and language
impairment, exceeds the cots of therapy by £741.8 million.

Within London, there were a total of 25.151 children with speech and language impairment
reported in 2009. This translates into a net benefit increased life-time earnings of £92.1
million.
3.2.6 The Children and Young People’s Commissioning Review of Therapies Services (2010/11)
The Therapies Review was conducted in Lewisham by the CYP (children and young people) Joint
Commissioning Team between October 2009 and April 2010 to:

Ensure the therapy needs of CYP in Lewisham are met and will continue to be met so
contributing to improving outcomes for children,

Identify current and future service gaps and develop options to ensure an equity of provision
across the borough, and

Ensure that therapy services are configured to deliver the highest quality of service within
allocated resources, therefore providing good value for money.
The review found that within a context of limited resources and increasing demands for therapy
services, available health resources need to be targeted more effectively at those children with
higher levels of clinical need. There was also found to not be a correlation between high clinical need
for speech and language therapy and having a statement.
The review recommended that core NHS therapy services funded by NHS Lewisham should be refocussed to provide intervention for school age children meeting the high clinical need threshold for
the service, and the moderate to high clinical need threshold for pre-school children. Furthermore,
Statements should be strengthened by the inclusion of clinical recommendations from therapists.
This should detail the level of clinical need for therapy provision – low, medium or high.
12
4. THE LEWISHAM PROFILE
4.1 Population profile
According to the results of Census 2011, the population of Lewisham is 275,900. This is a 14%
increase since 2001 and indicates that Lewisham has the 4th highest population of all London
boroughs.
Almost a quarter of Lewisham's population are aged 19 years and under (Figure 4.1) with under 5s
and primary school children each making up some 8% of the total population16.
Figure 4.1. The population of Lewisham by age (2011 Census).
ages >65,
26,100, 9%
ages <1,
4,700, 2%
ages 1-4,
17,300, 6%
ages 5-11,
22,900, 8%
ages 12-16,
15,400, 6%
ages 17-19,
9,800, 4%
ages 20-64,
179,700, 65%
Evelyn is the largest ward (total population 17,456, of whom 4634 are aged <20) but Downham
(total population 15,268) has the largest number of children and young people aged <20 (total
4,639)16. Downham also has the greatest proportion of children and young people <20 years (Figure
4.2).
13
Figure 4.2 Child population by ward, 2011 estimates (absolute numbers) 16
4.2 Population projections
Changes in the population age structure affect the need for health services. Population projections
therefore have an essential role in assessing the future need for services. Current trends in births,
deaths and migration are projected forwards and used to produce population projections.
14
Substantial population growth has been predicted for the next 30 years: rising from the estimated
274,900 in 2011 to 312,100 in 2031 - a rise of 14%. As today's children age, the adult population will
increase the most, however even in 2031, Lewisham will maintain a relatively young population
compared to the rest of England, and children aged under five years of age will remain an important
group. This needs to be taken into account when planning healthcare services in the future.
4.3 Prevalence of disability in Lewisham
As mentioned in the previous section, there is good evidence to accept that the prevalence of
disability in children as between 3-4% of children. In 2011, Dr. Tony O’Sullivan (Consultant
Community Paediatrician) estimated the numbers of children up to 16 years of age with disability
within the population of Lewisham in 2011. A report written by Public Health trainee Kate Tebbs in
2009 identified these estimates, which were originally calculated in 2005 and updated in 2011, to
still be the most accurate and comprehensive estimates available. An overview of these numbers is
shown in Figure 4.3, with the full table displayed in Appendix 1.
Figure 4.3 The number of children aged up to 16 years with disability in Lewisham stratified according to
disability type.
DOMAIN OF DISABILITY
Number per 1000 children
Learning difficulties
25-30
severe
4
moderate
20-25
Physical disability (all types)
3-4
cerebral palsy
Visual disability
2.5
1.9
isolated severe impairment
0.3
VI with other disability
1.6
Hearing: all children needing aids
severe hearing loss
2
1
15
Autistic spectrum disorders
15
core autism
2
wider spectrum
13
ADHD
50
10
Severe/hyperkinetic disorder
Developmental Coordination Disorder
50
56,000 children 0-16 – TOTAL (3%)
30-50 per 1000 =
1700-3400 children in Lewisham
The Triangle Schools Project in the north of the borough found prevalence rates of Speech, Language
and Communication needs of 30% in 5-16 year old children. However, over a 3 year period of
therapy input into the Triangle Schools (assessment, advice and intervention for children from
nursery to year 6 both with and without statements), prevalence rates of SLCN needs dropped to
7%, in line with the national average3.
Analysis conducted in 2007, showed that the total number of children, reviewed in the previous
three years, on the Lewisham Health Needs Register was 3958. In order to be included on this
register, children must be aged 0-19 years and should have at least one impairment of moderate or
greater severity, when assessed by the community paediatrics team. Using 2001 Census figures, the
total number of children living in Lewisham was 63,954. Therefore, the overall prevalence of
children with disabilities in Lewisham was estimated to be 6.2%.
The report ‘Disabled children: numbers, characteristics and local service provision’ was published by
the Department of Children, Schools and Families in 200817. The study was designed to estimate the
numbers of disabled children in each local authority in England by surveying all 150 Directors of
Children’s Services.
The study compared the numbers of disabled children from five sources of data: the total number of
children with Special Educational Needs (SEN) statements; the total number of children with SEN
(both with and without statements); the 2001 Census figure for the number of children with limiting
long-term illness; the number of children in receipt of Disability Living Allowance (DLA); and the
number of disabled children recorded in the Children In Need Census; with figures based on the
Office of Population Censuses and Surveys (OPCS), and estimates from the Family Resources Survey
16
(FRS). The numbers of disabled children recorded for Lewisham (based the population recorded in
2007) is shown in Figure 4.4.
Figure 4.4. Number of disabled children recorded in Lewisham17
Total no. of pupils with SEN statements (2007)
1158
Total no. of pupils with SEN (Primary & Secondary)
7614
No. of children with Limiting long-term illness aged 0-17 (Census 2001)
2819
No of children under 18 years in receipt of Disability Living Allowance (DLA) (2007)
1640
No of children recorded as disabled in the Children in Need Census (2003 and 2005)
335
Office of Population Censuses and Surveys (OPCS) estimate of prevalence of 1805 (3.2%)
disability in children (1985-1988) applied to population of children in Lewisham
Family Resources Survey (FRS) estimate of prevalence of childhood disability (2004- 4117 (7.3%)
2005) applied to population of children in Lewisham
The report also used estimated the upper and lower bounds of the number of disabled children in
each local authority based on the number of children with an SEN statement and the number of
children in receipt of DLA. They recorded the lower bound as the larger of these two estimates, and
the upper bound as the sum of the estimates. Therefore they recorded a figure of between 288000
and 513000 disabled children in England, which is between 3.0% and 5.4% of all children under 18
years of age. This relates to between 1787 and 3216 children in Lewisham experiencing some sort of
disability17.
4.4 The prevalence of children with therapy needs in Lewisham
Policy related to the prevalence of therapy needs in children comes entirely from the area of Speech
and Language therapy. The national prevalence of Speech, language and communication (SLC) needs
was identified in the Bercow Report in 2008 to be 7%13. The figure identifying SLC needs in children
is extensively quoted as ranging between 6-8% of children aged 0-11 years, with 1% of children
having severe, complex and long-term SLC needs requiring specialist support13,18,19.
The prevalence rates for SLC needs in children quoted above were estimated by Law et al in 2000 by
systematic review of literature related to screening for speech and language delay carried out for the
17
NHS in the UK. 16 prevalence estimates were generated from 21 included studies and a median
estimate was calculated as 5.95%20. In this review, Law et al commented on the apparent stability of
prevalence of SLC need amongst children in the UK over the 30 years included in the review (19671997) and suggested that this estimation of prevalence was not necessarily equivalent to an
estimation of the demands on a service. This may be in part due to the criteria used in this review
which included children with primary speech and /or language delays but not children with delays
secondary to other conditions such as ASD, or more general developmental disabilities. As
conditions such as ASD and other secondary speech and language delays may occupy a considerable
proportion of a Speech and Language therapist’s caseload – these estimates may be considered to
be an under-estimate of the prevalence of SLC need in children.
However, these prevalence rates still provide the most reliable estimates of SLC need in children.
When the prevalence rate of 7% used in the Bercow Report is applied to under 5 population in
Lewisham estimated by the Greater London Authority in 2011 (22040) this equates to approximately
1543 children, but the prevalence of SLC needs in under 5s in areas of high deprivation can be as
high as 55%3. The prevalence of SLC needs (10%) in 5-16 year olds applied to the Lewisham
population at this age (37925) equates to approx. 3973 children. It is important to note that the
prevalence of SLC needs in 5-16 year olds can be as high as 35% in areas of high deprivation3.
Approximately 1% of children entering school have the most severe and complex speech, language
and communication needs13. Therefore, this equates to approximately 220 children in the
population aged under 5 years, and 397 children aged 5-16 years with the highest level of SLC need.
18
5. THERAPY SERVICES FOR CHILDREN AND YOUNG PEOPLE IN LEWISHAM
This section is comprised of the information collected through semi-structured qualitative interviews
with key stakeholders is presented. All interviews were carried out in person. A full list of those
interviewed and a list of the main questions and topics explored with each stakeholder is included as
Appendix 1.
5.1 Speech & Language Therapy (SLT)
The Children and Young People’s Speech and Language Therapy Service (CYP SLT) aims to provide
community focussed evidence-based/informed services that anticipates and responds to the needs
of children and young people who experience speech, language, communication and / or swallowing
needs
The service works in partnership with children and young people, their families and other
professionals / agencies. The main aim is to raise awareness of speech, language and communication
needs, reduce the impact of these needs on a child’s well being whilst improving their ability to
participate in daily life, and improve life chances generally.
The service is configured around 2 pathways, the Under 5’s and School –aged services with subspecialities within. The children and young people are seen in local health clinics, nurseries,
community venues, children centres, schools and their homes.
19
The national prevalence of SLC needs (7%) identified in the Bercow Report in 2008, when applied to
under 5s in Lewisham equates to approximately 1534 children13. The prevalence of SLC needs (10%)
in 5-16 year olds applied to Lewisham equates to approx. 3973 children.
As mentioned in the previous section, approximately 1% of children entering school have the most
severe and complex speech, language and communication needs. This equates to approximately 220
children in the population aged under 5 years, and 397 children aged 5-16 years with the highest
level of SLC need.
The activity of the Speech and language therpy service from 1/4/2011 – 31/3/2012 in Lewisham can
be summarised as shown below:
The number of referrals accepted into SLT service:
1776
The total number of face-to-face contacts:
14956
The number of first face-to-face contacts:
1880
In line with the outcomes of the Commissioning Review of Therapies Services, the Core NHS Therapy
Services, funded by NHS Lewisham are being re-focused to provide Therapy interventions for those
children and young people with high priority levels of need. Intervention should follow clinical need
assessment meeting the high priority clinical need threshold for the service for school age children
and moderate to high priority clinical need for pre-school children. A Clinical profiling exercise was
undertaken out by the SLT team to identify the children on their caseload in March 2012 meeting
the threshold to access NHS Lewisham funded SLT. This is summarised below in Figure 5.1.
Figure 5.1. The number of children currently accessing SLT and numbers meeting the threshold to access NHS
Lewisham funded SLT
20
In March 2012, 848 children under 5 years of age are being prioritised with SLT needs in Lewisham.
Most of these children have been referred by their GP, Health visitor, or at the time of their
developmental assessment, and seen in the health centre or else at home. This is an ‘intervention’
service, rather than being an advice giving or consultative service.
Given the uncertainty that services are meeting need, it is essential that services identify and focus
on children with the highest level of need. However, there is no formal tool to identify children with
high level need. An extensive review of the key policy documents and peer-reviewed literature did
not identify a tool. Therefore is a need for local services to develop a tool, perhaps collaboratively
with an appropriate academic centre.
Recommendation 1: Speech and language therapists to develop and pilot tools for identification of
children with high clinical need across the under 5, mainstream school, and special school pathways.
21
This could be done collaboratively with an appropriate academic centre, is appropriate. . As part of
this tool, the term ‘high clinical need’ should be defined for the SLT service.
The identification of children with highest levels of for speech and language therapy needs is also
dependent on who is referred to the service. Speech and language therapists report a shift in
referrals with more children referred around the age of 2 years, rather than when older. Children
may not be referred if either families or services are able to support an individual child’s needs
without therapy input, or if they fail to recognise the potential benefit which investment in the child
during the early years could bring.
Children with high-level speech and language therapy needs as well as more complex needs, may
have a SEN statement and attend a Special School. However, due to the nature of communication
disorders, most children with high-level speech and language needs are maintained within the
mainstream school environment. The clinical profiling exercise undertaken by therapists identified
that few secondary aged pupils were seen for initial assessment by therapists during the 2010/11
academic year. This is likely to represent a significant under referral of secondary aged students. The
development of an education and training programme for healthcare and education professionals,
school staff, and parents could be a real asset to this SLT pathway, to ensure that the right children
are referred, and that the expectations of children and young people and their families are both
realistic and aspirational.
Recommendation 2: Robust education and training programme needed in schools to train healthcare
and educational professionals, including nursery staff and health visitors, how to refer to therapy
services and how to best support children with therapy needs.
Currently, if a child or young person with SLT needs has a Lewisham GP but attends a school outside
of Lewisham, for example in Bromley, Lewisham pays for the child to receive therapy in Bromley.
However, Lewisham, does not reciprocally charge Southwark, Greenwich or Bromley. This was
considered ‘unfair’ by the SLT therapists and thought to contribute to the financial and time pressure
on the service.
Recommendation 3: Consideration to be given to charging neighbouring boroughs for therapy needs
of their children attending school in Lewisham.
22
The Under 5 and school age SLT services provide different roles for children and young people with
SLT needs. The School age service is an advisory and consultative service and does not have the
capacity to provide interventions for all children and young people referred to them. The U5 service
however, does provide interventions but has no advisory service. There is currently a wait of up to 8
months for the U5 service and this wait may be reduced if, within the context of the therapies
review, a consultative or trouble-shooting SLT service was available.
Recommendation 4: Consideration should be given to the whether, within the context of the
therapies review, a baseline consultative and advisory service should be available for all children
referred to the SLT service in Lewisham, with interventions provided for children with specific needs
across both the under 5 and school-age service.
There is no paediatric SLT service within the hospital, with the exception of children with voice
problems. Whilst many children are referred to the Community SLT team, the speed of referral is
variable, often leading to considerable delay in accessing therapy for children. The methods of
referral to the SLT team needs to be addressed urgently, which better education regarding the
timely identification of children with therapy needs.
Recommendation 5: A review of the system of referral to Community SLT from the acute trust is
needed. This must include appropriate training for healthcare professionals to identify children with
high-priority therapy needs in order to minimise delay in referral.
Better collaborative working is needed not only between the therapies mentioned in this review, but
with other agencies and teams such as the Early Intervention Team, the Communication Interaction
Service, and Portage. It was highlighted by team leaders, therapists and service users alike that it
sometimes felt like they were all ‘chasing the same child’. Therefore better co-ordination is needed
to optimise results, and to ensure that the child or young person and their family feel adequately
supported, but not under pressure to comply with competing demands of the services. A joint initial
assessment is one way in which this could be addressed. This shall be discussed in more detail in
Section 5.4.
Recommendation 6 A single point of referral, leading to a joint initial assessment clinic with
representatives from multiple therapies could be useful to effectively prioritise the therapy needs of a
child.
23
5.2 Occupational Therapy (OT)
Lewisham’s Community Children and Young People's Occupational Therapists provide assessment,
intervention, support and advice for children and young people living in the community.
All referred children need support to participate in occupations of daily life. This covers the areas of
self-care, play/leisure, life skills and school life. Intervention is person-centred and is provided in
collaboration with the child or young person, where their motivation and concerns, are key.
Intervention can be carried out directly with the child or young person but may also be provided
through supporting family members, teachers and other carers to incorporate specific strategies in
enabling the child or young person on a daily basis.
The service is based in Kaleidoscope, Lewisham Centre for Children and Young People in Catford,
South East London and is commissioned by Lewisham PCT, through joint commissioning
arrangements. It provides a service to families with a GP in Lewisham and/or children who attend a
Lewisham school. Two Occupational Therapists and a 0.5 assistant are employed by Lewisham Local
Authority and are based with the service enabling closer working between agencies for some
children. Increased integration between these two services has been comprehensively explored.
Draft pathways and systems for collaborative working have been sketched out, in support of this and
amongst the respective teams there is a willingness to develop an integrated team.
The Community Occupational Therapy service in Lewisham has undergone significant expansion
within the last 18 months. Prior to this time, a limited OT service was provided only to children and
young people who attended Special Needs Schools in Lewisham. However, the service now has
Under 5 and school age services and children are also seen at Greenvale special school, Watergate
nursery and mainstream nurseries, with one OT post funded for children with statements
specifically.
The activity of the Occupational therapy service from 04/2011 – 03/2012 in Lewisham can be
summarised as follows:
Total number of referrals to the OT service: 380
Total number of referrals accepted into the OT service: 293
Total number of discharges from the OT service: 288
Total number of first face-to-face appointments: 406
24
Totally number of face to face appointments: 2846
As with SLT, there is currently no way of determining whether the children with the highest level of
need are being priorised by the Occupational Therapists. Following on from the work conducted
within SLT team, the OT service has begun to develop tools to assist with the prioritisation of
children with high level needs. Separate tools are being developed for children who are under 5,
those attending mainstream schools, and for special school referrals. This work is at its infancy, and
needs to continue development, and be piloted and validated before being introduced throughout
the service.
Recommendation 7: Occupational therapists to develop and pilot tools for identification of children
with high clinical need across the under 5, mainstream school, and special school pathways. As part
of this tool, the term ‘high clinical need’ should be defined for the OT service.
There is no OT provision for children with ASD and this has been highlighted as a major service gap,
impacting far beyond the OT service and involving other therapy goals. The speech and language
therapists cited as an example, that in order for a child to drink out of a cup, they need SLT input but
may also need OT and possibly physiotherapy too. A lack of OT provision for children with ASD, may
impact the level at which other therapies can be aimed, and may cause less attainment from
children than would otherwise be possible. This needs to be addressed as a priority.
Recommendation 8: The level of need for a designated autism pathway for occupational therapy
needs to be described. This should take into account the impact of the OT service on the effectiveness
of the other therapists for children with ASD.
There are two children and young people’s community Occupational therapy teams at Lewisham –
within Health, which is the team interviewed for this report, and within the local authority
positioned within Social care. The stakeholders interviewed felt that there was a large amount of
overlap within these two teams. The role of the local authority team mainly issued appliances for
children and families without providing interventions or other techniques, provided by the Health
team. Multiple instances were highlighted where time spent teaching children useful adaptations
and techniques completely removed the need for this equipment.
In 2002, ‘From interface to integration: a strategy for modernising occupational therapy services in
local health and social care communities’ was published by the College of Occupational Therapists
to address the interface existing between occupational therapy services provided by health and
25
social care agencies. The publication proposed an approach to a solution for tackling this interface.
Since this time, many community health and social care Occupational therapy services have merged
to from integrated Occupational Therapy services including children’s services in Croydon, Tower
Hamlets, Torbay and East Cambridgeshire. In particular, integration of the service in Cambridgeshire
was preceeded by a 1 year pilot integrating health and social care role, with a schedule for
integration published in 2006 (reference). The advantages of an integrated OT service were noted
and documented at Torbay Care Trust with an NHS OT commenting on the new arrangements that:
“Yesterday I got all the background I needed from the ‘Social care’ OT to take back direct to the
patient . We reckoned this saved about 5 hours of our time.’’
Previous work was undertaken in Lewisham in 2009 to review various ‘merger options’ and
recommended the integration of Local Authority children and young people occupational therapists
into the Community Health team in order to achieve ‘service join up’ and ‘improve the experience of
both services for children and their families’. Plans for this merger should be revisited in order to
avoid further duplication of resources.
Recommendation 9: The integration of Local Authority children and young people occupational
therapists into the community health team must be undertaken in order to achieve a more joined up
effective service and avoid duplication of resources.
5.3 Physiotherapy
The CYP Community Physiotherapy Service provides physiotherapy assessment, interventions and
advice for children and young adults aged 0-18 (19 when in full-time education) with neurodevelopmental disabilities and related conditions in their homes, nurseries, mainstream and special
schools and in clinics based at Kaleidoscope.
There are Paediatric Physiotherapy services within Lewisham Hospital and an acute out-patient
setting for all conditions that do not match the criteria of neuro-developmental disabilities. If a child
or young adult develops a neuro-developmental condition as the result of a trauma / acute episode,
the CYP Community Physiotherapy Service will undertake an assessment and assist within planned
discharge from an acute to community setting.
The activity of the Physiotherapy service from 04/2011 – 03/2012 in Lewisham can be summarised
as follows:
26
Total number of referrals to the Physiotherapy service: 387
Total number of referrals accepted into the OT service: 382
Total number of discharges from the OT service: 411
Total number of first face-to-face appointments: 51
Totally number of face to face appointments: 5605
The Community Physiotherapy service covers mobility concerns for children and young people up
until 19 years of age in Lewisham. These concerns may range from a child not walking at 16 months,
to the development of a ‘funny walk’, to a child with cerebral palsy of the whole body who may stay
with the service right up until 19 years of age. The Community service does not include musculoskeletal concerns, for example rehabilitation after a broken leg, and children with these conditions
remain completely under the care of the physiotherapists at the acute trust.
Children and young people may be referred to the service by their GP, which happens only rarely, or
by Community Paediatricians, hospital doctors or by out of borough sources. Unlike the other
therapies, referrals are not accepted from parents or educational sources as it is felt that a medical
review is needed first. Once a child is referred, a decision is made regarding whether this is a routine
or priority referral and the child is reviewed in the initial assessment clinic, which lasts for 1 hour and
during which both the parent and child are present.
Children are prioritised according to severity to attend either the first steps clinics, if they are under
5 years of age, or the review clinic, which caters for children of school age. Children with very high
levels of need, may require more intensive therapy, but this is dependent on potential for
improvement. The physiotherapy teams also go into special schools, as well as mainstream schools
on a case-by-case basis to show a support worker or one-to-one carer how to, for example, help to
position a child or young person.
Work is beginning to develop tools to help with the prioritisation of children and young people with
the highest therapy needs in order to ensure that these children are seen within the service. Within
the physiotherapy service, these tools are yet to be developed, as other tools have previously been
trialled within the service. In particular the Nottingham derived tool was used, but deemed to not
quite fit as it, like other existing tools, do not take into account the ‘social situation’ of the child or
young person, which is felt by the Lewisham team to be very important. Therefore, the positive
aspects of the existing tools, should be combined with the clinical input of the team, to create their
own prioritisation tool, which shall be piloted and validated prior to use throughout the
27
physiotherapy service. The physiotherapy service also includes orthotics services and it is known that
the orthotic needs of a child or young person are often different to physiotherapy needs. Therefore
separate tools will need to be developed to aid prioritisation of children and young people according
to the level of their orthotic needs.
Recommendation 10: Physiotherapists to develop and pilot tools for identification of children with
high clinical need across the under 5, mainstream school, and special school pathways. As part of this
tool, the term ‘high clinical need’ should be defined for the physiotherapy service.
.Recommendation 11: Orthotics services will need own criteria for identifying children with highpriority clinical need.
Stakeholders highlighted problems in obtaining the correct equipment needed to support children
and their families. The system for requesting equipment is convoluted, and continually provides
inaccurate information leading to the wrong item being sent for a particular child. It was reported
that this often leads to therapists having to go physically to Southwark and view equipment prior to
ordering. The inefficiencies of this service impacts far beyond the immediate therapy needs of a
child. For example, if a child needs a special chair in order to be able to attend school and this is
normally identified as being in stock and ordered. If on arrival, the chair turns out to be a frame
which was incorrectly labelled, correct chair now needs to be bought in, this can lead to a delay
during which time the child cannot attend school.
Recommendation 12: Difficulties getting equipment for children must be resolved as a priority due
to the impact this has on children being able to access nursery or school.
Once a young person without a learning disability reaches the age of transition to adult services,
there are no services to support them with therapy needs and this is another service gap. Whilst
transition planning begins at 14 years of age, the lack of an identifiable person to handover therapy
information to, is short-sighted. The current adult physiotherapy service provides input if a
significant event occurs i.e. if someone suddenly becomes ‘off-legs’. To enable even this to happen
effectively, knowledge of a young person’s previous therapy input and needs is essential, otherwise
unrealistic therapy goals may be set.
Recommendation 13: Lack of regular therapy services within adult services if no learning disability
needs to be planned for from 14 years of age. A key person needs to be identified within adult
services for handover to occur.
28
5.4 Joint working
Joint working both between the therapies, and with other agencies and services was highlighted as
key in order to support the therapy needs of children and young people and their families
adequately.
5.4.1 Joint working between therapies
Discussions with both therapists and other health professionals has highlighted that the community
therapy services in Lewisham are considered to be very good, but demand is high across the
pathways of the three therapies. Whilst recommendations have been made for each therapy
individually, which would help to both identify the children with the highest level of need and divert
resources where needed most, there are potential areas of service integration and resource pooling,
which may be beneficial across all the therapy pathways.
The therapists commented repeatedly that it felt as if they were ‘chasing the same children’, and
multiple appointments in close proximity can be distressing for the child or young person and timeconsuming for their families and carers. One way in which this could be addressed is by a single point
of referral to all therapies, leading to a joint initial assessment clinic. This would highlight the therapy
priorities for a child, and for those needing multiple therapy input, allow prioritisation to occur. This
joint clinic may also have the potential to provide a ‘quick advisory’ service prior to full referral to
identify children not suitable for services or who could undergo a period of observation prior to
formally being seen by a therapist.
Recommendation 6: A single point of referral, leading to a joint initial assessment clinic with
representatives from multiple therapies could be useful to effectively prioritise the therapy needs of a
child.
Recommendation 14: The potential for ‘quick advisory’ service which may identify children not
suitable for services or who could undergo a period of observation prior to being formally seen by a
therapist could be investigated to help reduce the burden on the therapy services.
There could also be the scope for joint therapy sessions to occur, therefore minimising the time
spent by each therapist with each child, but using a more integrated approach to achieve therapy
goals. A more integrated pathway between therapies with scope for cross-over between therapies
could also be investigated, e.g. the use of a ‘key-worker’ therapist who delivers generic care to avoid
multiple over-lapping healthcare professionals.
29
Recommendation 15: The use of joint therapy sessions could be investigated as a more integrated
approach to achieve therapy goals may result in goals being reached sooner and more effectively.
Recommendation 16: More integrated pathway between therapies with scope for cross-over
between therapies could be considered, e.g. a ‘key-worker’ therapist who delivers generic care to
avoid multiple over-lapping healthcare professionals.
5.4.2 Joint working with other agencies and services
It is widely acknowledged that the sooner a child or young person’s therapy needs are identified and
addressed the better for the child and their family. Therefore emphasis is needed to identify children
at a younger age, through better education in nurseries and schools, and targeted health visitor
training, in order for therapy to be started early. Good communication with agencies and services
such as the Multi-agency Planning Pathway (MAPP) and Portage services are needed to avoid
children both slipping between services and receiving care from multiple overlapping services.
Recommendation 2: Robust education and training programme needed in schools to train healthcare
and educational professionals, including nursery staff and health visitors, how to refer to therapy
services and how to best support children with therapy needs.
Recommendation 17: Good communication with agencies and services such as the Multi-agency
Planning Pathway (MAPP) and Portage services are needed to avoid children being missed by
services.
6. CONCLUSIONS
This comprehensive review of therapy services for children in Lewisham has revealed that there are
some important areas that the Partnership will need to address in order for a sustainable service and
the best possible care to be available for children and young people in Lewisham:

Therapy team leaders must urgently develop and pilot tools for the identification of children
with high clinical need across the under 5, mainstream school and special school pathways.
As part of this tool, the term ‘high clinical need’ must be defined separately for the speech
and language, occupational therapy and physiotherapy services (Recommendation 1, 7 and
10)
30

The level of need for a designated autism pathway for occupational therapy needs to be
described. This should take into account the impact of the OT service on the effectiveness of
the other therapists for children with ASD. (Recommendation 8).

The integration of Local Authority children and young people occupational therapists into
the community health team must be undertaken in order to achieve a more joined up
effective service and avoid duplication of resources (Recommendation 9).

Robust education and training programme needed in schools to train healthcare and
educational professionals, including nursery staff and health visitors, how to refer to therapy
services and how to best support children with therapy needs (Recommendation 2).

Ways in which therapists work together to optimise the therapy goals of children, for
example through a joint initial assessment clinic, should be considered (Recommendation 6,
15 and 16).
A comprehensive list of all recommendations made in this report is included in Section 7.
7. RECOMMENDATIONS
Recommendation 1: Speech and language therapists to develop and pilot tools for identification of
children with high clinical need across the under 5, mainstream school, and special school pathways.
This could be done collaboratively with an appropriate academic centre, is appropriate. . As part of
this tool, the term ‘high clinical need’ should be defined for the SLT service.
Recommendation 2: Robust education and training programme needed in schools to train healthcare
and educational professionals, including nursery staff and health visitors, how to refer to therapy
services and how to best support children with therapy needs.
31
Recommendation 3: Consideration to be given to charging neighbouring boroughs for therapy needs
of their children attending school in Lewisham.
Recommendation 4: Consideration should be given to the whether a baseline consultative and
advisory service should be available for all children referred to the SLT service in Lewisham, with
interventions provided for children with specific needs across both the under 5 and school-age
service.
Recommendation 5: A review of the system of referral to Community SLT from the acute trust is
needed. This must include appropriate training for healthcare professionals to identify children with
high-priority therapy needs in order to minimise delay in referral.
Recommendation 6: A single point of referral, leading to a joint initial assessment clinic with
representatives from multiple therapies could be useful to effectively prioritise the therapy needs of a
child
Recommendation 7: Occupational therapists to develop and pilot tools for identification of children
with high clinical need across the under 5, mainstream school, and special school pathways. As part
of this tool, the term ‘high clinical need’ should be defined for the OT service.
Recommendation 8: The level of need for a designated autism pathway for occupational therapy
needs to be described. This should take into account the impact of the OT service on the effectiveness
of the other therapists for children with ASD
Recommendation 9: The integration of Local Authority children and young people occupational
therapists into the community health team must be undertaken in order to achieve a more joined up
effective service and avoid duplication of resources.
Recommendation 10: Physiotherapists to develop and pilot tools for identification of children with
high clinical need across the under 5, mainstream school, and special school pathways. As part of this
tool, the term ‘high clinical need’ should be defined for the physiotherapy service.
.Recommendation 11: Orthotics services will need own criteria for identifying children with highpriority clinical need.
Recommendation 12: Difficulties getting equipment for children must be resolved as a priority due
to the impact this has on children being able to access nursery or school.
Recommendation 13: Lack of regular therapy services within adult services if no learning disability
needs to be planned for from 14 years of age. A key person needs to be identified within adult
services for handover to occur.
32
Recommendation 14: The potential for ‘quick advisory’ service which may identify children not
suitable for services or who could undergo a period of observation prior to being formally seen by a
therapist could be investigated to help reduce the burden on the therapy services.
Recommendation 15: The use of joint therapy sessions could be investigated as a more integrated
approach to achieve therapy goals may result in goals being reached sooner and more effectively.
Recommendation 16: More integrated pathway between therapies with scope for cross-over
between therapies could be considered, e.g. a ‘key-worker’ therapist who delivers generic care to
avoid multiple over-lapping healthcare professionals.
Recommendation 17: Good communication with agencies and services such as the Multi-agency
Planning Pathway (MAPP) and Portage services are needed to avoid children being missed by
services.
8. REFERENCES
1. http://www.legislation.gov.uk/ukpga/2010/15/contents
2. Department of Education. Support and aspiration: a new approach to special educational needs
and disability. March 2011
3. Department of Health. National Service Framework for Children, Young People and Maternity
Services. Oct 2004.
4. Audit Commission. Services for Disabled Children. Sept 2003.
5. http://research.dwp.gov.uk/asd/asd5/ihr/ih019.pdf
6. Bone M AND Meltzer H. The prevalence of disability among children. OPCS surveys of disability
in Great Britain, Report 3. HMSO, London, UK. 1989.
7. Gordon, D et al. Disabled children in Britain: a re-analysis of the OPCS disability surveys. The
Stationery Office, London, UK. 2000.
8. Nessa N. Office of National Statistics. The health of children and young people. Chapter 10:
Disability. March 2004.
33
9. http://research.dwp.gov.uk/asd/frs/
10. Blackburn CM, Spencer NJ, Read JM. Prevalence of childhood disability and the characteristics
and circumstances of disabled children in the UK: secondary analyses of the Familty Resources
Survey. BMC Pediatrics 2010, 10:21
11. Read J, Blackburn C, Spencer N: Disabled children in the UK: a quality assessment of
quantitative data sources. Child: Care, Health and Development 2009, 36(1):130-41.
12. Ofsted. The Special Educational Needs and Disability Review. September 2010.
13. The Bercow Report: A review of services for CYP 0-19 with Speech, Language & Communication
Needs 2008
14. HM Treasury & Department for Education and skills. Aiming high for disabled children: better
support for families. May 2007.
15. Matrix Evidence. An economic evaluation of speech and language therapy. December 2010.
16. http://data.london.gov.uk/datastore/package/gla-demographic-projections
17. http://eprints.ioe.ac.uk/61/1/Numbers_and_characteristics_of_disabled_children.pdf
18. Gascoigne M. (2006) “Supporting children with speech, language and communication needs
within integrated children’s services”RCSLT Position Paper, RCSLT: London
19. http://www.ican.org.uk/~/media/Ican2/Whats%20the%20Issue/Evidence/ICAN_TalkSeries9.as
hx
20. Law J, Boyle J, Harris F, Harkness A, Nye C. Prevalence and natural history of primary speech
and language delay: findings from a systematic review of the literature. Int J Lang Commun
Disord. 2000. 35 (2): 165-88
21.
34
APPENDIX I
Eligibility criteria for Family Fund Trust (FFT) financial assistance
1.
Children and young people must have additional complex needs, or have a serious or lifethreatening illness.
2. There must be evidence that the child or young person’s additional needs impact on a
family’s choices and their opportunity to enjoy ordinary life. The degree of planning and
support required to meet their needs must also be much greater than that usually required
to meet the needs of children and young people.
3. Children must require a high level of support in three of more of the following areas:
 The physical environment
 Education
 Communication
 Access to social activities
 Personal care, supervision and vigilance
 Specialist resources, including Information and Communications Technology*
 Medical or therapeutic treatment and condition management
35
4.
The child or young person’s condition must be long-term or life-limiting. By long-term we
mean lasting or likely to last 12 months or more.
*Essential
36
Appendix 2. Prevalence model for disability in Lewisham (Model developed by Dr. Tony O’Sullivan in 2005, and updated for current/projected figures in
2011. Projections based on 5000 births/year in Lewisham).
Prevalence model for
disability in Lewisham
Incidence
Area of special
need/impairment/disability
per 1000
children
Incidence per
year (5000
births/year)
Lewisham
prevalence
0 – 4 yrs 11 mths
Projected
Lewisham
prevalence
Projected
Lewisham
prevalence
5 -15 yr 11 mths
16 - 19y if 5000
births/year
continue
severe

moderate
current population
55,000 0-16y
(up to 16th birthday)
1595
Learning disability

Total estimated
prevalence in
4
20
100
220
60
220
25
125
375
1375
-
1375
Physical disability
3-4
17.5
88
193

cerebral palsy
2.5
12.5
63
99
38
132

muscular dystrophy
0.15
0.75
4
6
not estimated
8-9
15
75
225
825
not estimated
695
10
50
150
primary
not estimated
450 up to 11y
Autistic spectrum disorder
(1.5%)
150
(80% with significant learning diff)
speech and language
delay/disorder

language disorder/significant
language delay
300
conservative
37
estimate
hearing loss requiring aids

2
10
severe hearing loss
moderate hearing loss (aided)
visual impairment (VI)



1.9
50
106
110
5
25
55
5
25
55
9.5
48
not estimated
53
53
101
106
isolated severe VI
(0.3)
1.5
7.5
18
partially sighted
(1.6)
8
40
88
not estimated
16
85
motor planning disorders

developmental coordination
disorder
1% severe (up to 5% mild)
10
50
150
50
-
210+
590
530 +
550
behavioural/attentional disorders

hyperkinetic disorder 1%
10

(all types of ADHD)
(50)
(13)
500
(13)
not estimated
530 +
70-80
1600-2200
TOTAL
(not double counting autism and
learning difficulty)
55-65
2242
(3-4%)
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APPENDIX 3 List of key stakeholders interviewed and main questions asked
List of stakeholders
Dorrett Davis
Therapies lead covering Speech and language therapy, Physiotherapy and
Occupational therapy
Carol Etheridge
Community Physiotherapy lead
Christine Hannan
Community Speech and Language therapy for over 5s lead
Dr. Tony O’Sullivan
Consultant Community Paediatrician
Alison Royle
Community Occupational Therapy lead
Sam Spencer
Community Physiotherapy lead
Ros Swift
Community Speech and Language therapy for under 5s lead
Ann Wallace
Team leader for MAPP/ Portage services
Main interview questions
What do you think the issues are?
What is the biggest problem? 3 biggest problems?
How would you define high-level clinical need?
Is there a model service for therapies for children with high-level clinical need or a service which has
improved its service recently?
How do you think our service is doing compared to this?
What is different between the assessment for SALT/OT/PT in mild/moderate and severe children?
Do you think the right children i.e. those with most need are being seen by the therapists? How can
we ensure that this happens in Lewisham?
What’s different between the pathway which children with low/ moderate and high-level needs
follow?
Do you know of any validated tools/national guidance or pathways which could be used by the
therapists (OT/PT/SLT)?
What has been done to review caseloads?
Do we know what levels or parent/teacher satisfaction with therapy services are? Are there any
specific complaints that have been made regarding aspects of the service?
What’s the one thing you would change? What are the top 3 things? 5 things?
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