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CHAPTER 15: THE HEALTH SERVICE AND THE SOCIAL SERVICES
INTRODUCTION
15.1 The health service and the personal social services make an essential contribution to meeting the educational needs of children with disabilities or significant difficulties. The evidence presented to us and our own visits underlined the importance of close collaboration between these services and the education service in providing help for children with special needs and their families. The need for an awareness on the part of the members of all these services of the nature of each other's contribution also emerged very clearly. It has not been our purpose to comment in detail on the work of the health and social services. In the course of our report, however, we have identified areas of interest and responsibility common to the education, health and social services and have made proposals for the development of collaboration between them in particular ways. We cannot stress too strongly that the effective development of special education along the lines we have proposed requires wholehearted co-operation between the health, social and education services.
15.2 We do not think that it is any part of our brief to comment on the wisdom or otherwise of the reorganisation of the health services and of local government (in England and Wales in 1974 and in Scotland in 1974 and 1975), except to say that in some very important respects reorganisation made co-operation at local level, which we seek to promote, more rather than less difficult. However, given the present structures and systems, we turn to aspects of health and social services which are particularly important to the special educational arrangements proposed in this report. We also consider the contributions of some of the different professionals working within these services. Many issues have been discussed in the context in which they arose, for example in the context of assessment in Chapter 4 and of the needs of young people with disabilities in Chapter 10, and we do not propose to repeat our views on these matters in this chapter.
15.3 The provision of help and support for children with special educational needs and for their families in their own homes, in schools and in the neighbourhood is a task which health and social services share with education. We welcome the statement by the Secretary of State for Social Services on the Court Report on 27 January 1978 in which he said: 'I am asking health authorities to examine each component part of their child health services - primary care, community services and specialist services to see how best to produce the integration of services to which the Court Committee rightly attached such importance. But in this field, as in so many others, the health services must work in tandem with local authority services which reach out to children and their families. Special effort by all those services is needed to find those families
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who most need help and are least likely to seek it out'. (1) We regard the task of discovering, assessing and providing for children with special educational needs as a shared one which merits very high priority, particularly in areas (mainly, but not exclusively, inner city areas) where there are adverse social conditions.
I THE HEALTH SERVICE
15.4 Public concern about ill health, malnutrition and disabilities in school children led to the appointment of school doctors at the beginning of this century. The school health service was established in 1908 and its development in England and Wales up to the reorganisation of the national health service in 1974 is described in a recent publication. (2) Over that period many changes have taken place in the incidence and nature of health problems in children. Infectious diseases have been largely controlled and better nutrition, public health and housing have helped to reduce the incidence of illness and disability. Advances in medical diagnosis and treatment have also led to changes in the pattern of handicapping conditions. Congenital malformations, disorders arising in the newborn and problems arising from the social and emotional climate in which children grow up now account for a much greater proportion of child health problems.
15.5 The reorganisation of the health service in 1974 resulted in the transfer of responsibility for the school health service from local education authorities to area health authorities and of that for community child health services from local health authorities to area health authorities. The reorganisation was intended to result in a comprehensive service in which the school health service was integrated with other child health services and with hospital and specialist services which, together with general practitioner services, would cover all health services for children. This goal has not yet been achieved. Whilst the reorganisation was in the planning stage the report Towards an integrated child health service (3) described the possible development of the child health service in Scotland. Since reorganisation the future of health services for children in England and Wales has been studied by the Court Committee which reported in 1976. (4) We entirely agree with that Committee's view that 'the child health service and education services must see themselves as engaged, to a large extent, upon different aspects of a common task'. During the period when the Committee was sitting many initiatives awaited its recommendations. Now that the government has announced its conclusions on the Committee's recommendations (5) we hope that no time will be lost in strengthening health services to schools. We regard a properly structured school health service as essential for all children and particularly for those with special educational needs.
(1) DHSS Health Circular HC(78)5 Local Authority Circular LAC(78)2, Welsh Office Circular WHC(78)4, Health Services Development (January 1978), Annex A.
(2) The School Health Service 1908-1974 (HMSO 1975).
(3) Towards an Integrated Child Health Service Joint Working Party on the Integration of Medical Work. Report of a Sub-Group on the Child Health Service (HMSO 1973).
(4) Fit for the future The Report of the Committee on Child Health Services. Cmnd 6684 (HMSO 1976).
(5) DHSS Health Circular HC(78)5 Local Authority Circular LAC(78)2, Welsh Office Circular WHC(78)4, op. cit.
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Delivery of health services
15.6 There are four essential features of good health services for children with special educational needs: professional skill; availability; continuity; and adequate understanding and experience of education. We review below the delivery of health care to children with special needs, bearing in mind the importance of these four features. A detailed account of the organisation of the health service in England, Scotland and Wales is given in Appendix 4.
15.7 School health services in England and Wales are provided by area health authorities to matching local education authorities. The Area Specialist in Community Medicine (Child Health) and the Area Nurse (Child Health) in England and Wales have dual responsibilities to, and are appointed with the agreement of, both the area health authority and the local education authority. They work particularly closely with local education authorities, and their functions are crucial to good health services for special education. The services to be provided, which are described in detail in a Circular issued by the Department of Health and Social Security on the reorganisation of the health service, (6) include the provision of medical staff, nurses and therapists to ordinary and special schools; arrangements for medical examinations and immunisation; and the oversight of health care in schools. Particularly important among these services, in view of our recommendations elsewhere in this report, are advice to parents, teachers and local education authorities on the nature and extent of handicapping conditions or other medical conditions significant for a child's education, participation in health education and the provision of counselling services for pupils and others.
Primary health care
15.8 General practitioners have traditionally been the first point of contact for children and their families seeking medical advice and treatment. Although independent contractors, they need to maintain close links with colleagues in other parts of the health service and in other services and agencies, such as social services. In recent years some general practitioners have accepted the concept of team work, with the attachment of health visitors, district nurses and social workers to general practice. This team approach is a developing one, but we recognise that for many different reasons the establishment of such teams may be difficult.
15.9 General practitioners and clinical medical officers share responsibility for the health surveillance of children and advice to their parents. Collaboration and communication between these doctors are essential for the provision of an effective service. Moreover, they have a responsibility to ensure that local authorities are aware at the earliest opportunity of children's special needs so that appropriate steps can be taken to meet them. Health visitors, whose main duties include visiting homes where there are babies and young children, may be the first members of the health service with whom some families come into
(6) Department of Health and Social Security Circular HRC(74)5, Welsh Office Circular WHRC(74)7, Operation and Development of Services: Child Health Services (including School Health Services) (January 1974) Annex 3.
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contact after the child's neonatal period. They work closely with general practitioners and clinical medical officers in the health surveillance of children and therefore in the early identification of those with problems.
Child health services in schools
15.10 We endorse the aims of child and school health services in relation to education which were identified in the Court Report, namely: i. to promote the understanding and practice of child health and paediatrics in relation to the process of learning; ii. to provide a continuing service of health surveillance and medical protection throughout the years of childhood and adolescence; iii. to recognise and ensure the proper management of what may broadly be described as medical, surgical and neurodevelopmental disorders, insofar as they may influence, directly or indirectly, the child's learning and social development, particularly in school, but also at home; iv. to ensure that parents and teachers are aware of the presence of such disorders and their significance for the child's education and care; and v. to give advice and services to the local education authority as required by the Education Act 1944 and the National Health Service Reorganisation Act 1973. We have been concerned that these aims may not receive sufficient priority in the health service. However, we are encouraged by the Secretary of State for Social Services' response to the Court Report, in particular his wish to see improved child health services especially in areas of greatest social need. The importance of such services to schools cannot be overemphasised if children with special educational needs are to receive effective help. We therefore recommend that health authorities should make adequate resources available to promote effective child health services in ordinary and special schools.
15.11 We regard the functions of Specialists in Community Medicine (Child Health) as particularly important to the development of effective special educational provision. Being in the special position in England and Wales of working for both the area health authority and the local education authority, they are able to provide valuable links between the two. Their responsibilities include ensuring that information about special needs discovered by primary care services, community health and hospital services is conveyed to the education authority; arranging for the medical aspects of assessment which we described in Chapter 4; ensuring that necessary medical services and the services of other professionals in the health service are made available to educational institutions; and generally advising the education authority on all matters concerned with child health and educational medicine.
15.12 It has been put to us that there is likely to be a shortage of Specialists in Community Medicine with training and knowledge of educational and school health problems. We believe that this potential problem is receiving far too little attention. We therefore recommend that as a matter of urgency high priority should be given to the recruitment and appropriate training of doctors for this field of work. We urge local education authorities in England and Wales, whose agreement to the appointment of Specialists in Community Medicine (Child Health) is required, not to consent to the appointment of doctors without adequate clinical and educational experience. Similarly, in giving their agreement to the appointment of Area Nurses (Child Health) local education authorities should ensure that those appointed have relevant experience.
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Discovery, assessment and support
15.13 In Chapter 2, where we reviewed the history of special education, we explained that the Education Act 1944 introduced the requirement of a medical examination to determine whether a child was handicapped. This provision was a logical outcome of the concern shown by school medical officers for handicapped children since the inception of the school health service. Since that time the importance of psychological, educational and social as well as medical assessment has been recognised. The Sheldon Working Party (7) recognised the importance of multi-professional assessment in hospitals and elsewhere and Circular 2/75 emphasised the inter-professional character of discovery, diagnosis and assessment, (8) as did the Education (Scotland) Act 1969 and the Brotherston Report. (9) In supporting this trend and in recommending new procedures for assessment (see Chapter 4) we in no way wish to diminish the importance of medical examinations of all kinds for children with special needs. We wish only to emphasise the need for these to be carried out in association with members of other professions if a complete picture of an individual's needs and the means of meeting them is to be compiled.
15.14 Our recommendations for procedures for discovering, assessing and meeting special educational needs impinge upon many aspects of the health service. Those professionals, doctors and others, concerned with primary and community health care will be in contact with many of the children who are likely to require special educational provision at some time during their school career. Professionals in a wide range of hospital and specialist services, including ophthalmic, orthopaedic, Ear, Nose and Throat, paediatric and child psychiatric specialists, may also be in contact with children with special educational needs, and will have responsibilities for those with more complex problems.
15.15 We stressed in Chapter 4 the importance of health surveillance and screening procedures for young children, particularly in order to identify children for whom early education is vital, such as those with impaired hearing. In the case of children under five, members of the health service responsible for primary care or community health care will often be the first professionals to notice disabilities and significant delays in development, as we indicated in paragraphs 15.8-9. They may also be the first to whom parents turn for advice and guidance when they are worried about their child's development. It is therefore important that all the professionals concerned should be well informed of the possible educational implications of the problems that they recognise. They should also be aware of the services available to meet the needs of such children, including special education services, and should recognise the need to keep the education service informed through the Specialist in Community Medicine (Child Health) about children with special needs. They may also play an important part in helping children when they first enter school by supporting parents and working closely with teachers. Where the health visitor is acting as
(7) The Report of the Working Party under the chairmanship of Sir Wilfred Sheldon was not formally published but was circulated to regional hospital boards and local health authorities in 1968. It was subsequently referred to in DHSS HM(71)22, Hospital Facilities for Children.
(8) DES Circular 2/75, Welsh Office Circular 21/75, The Discovery of Children Requiring Special Education and the Assessment of their Needs (17 March 1975).
(9) Towards an Integrated Child Health Service, op. cit.
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the Named Person for a family she should continue to act in this capacity until the parents are informed of the Named Person who will succeed her.
15.16 Procedures for assessment, for the communication of medical information and for medical and nursing support in schools will, in our view, develop to the full only if there are opportunities for regular discussion between members of the health service and teachers who are known to each other. Regular contact between doctors, nurses and class teachers about individual children is essential to the development of health education and counselling as well as to the discovery of special needs. The staff of each school must know the names of members of the health service to whom they can turn for advice and help.
15.17 We see the need for a nominated doctor and nurse for every school. The doctor will in most cases be a clinical medical officer (child health). The doctor and nurse will play a very important part in health surveillance in school, which may be the only contact that some children have with health services. They may also be instrumental in the discovery of special educational needs, which can arise at any time during a child's school career. We envisage that their contribution to the help and support of children with disabilities in ordinary schools will increase as the progressive implementation of Section 10 takes place. In those areas, for example in inner cities, where social disadvantage is most manifest, the work of the school doctor and nurse will be especially important. We therefore recommend that there should be a named doctor and nurse for every school.
15.18 The Court Report recommended that, as a way of improving links between health services and special education, each special school should have a consultant community paediatrician as its doctor. Although the creation of this new specialist has not been accepted, we consider that the idea should be the subject of experiment and discussion at area health level, as suggested by the Secretary of State for Social Services in his statement on the Court Report on 27 January 1978. Where children with disabilities are educated in ordinary schools, it is important that the doctors concerned with their health should gain direct experience of educational settings in ordinary schools. Moreover, paediatricians working in hospitals and other hospital specialists should have more contact with children in schools. As we emphasised in Chapter 7, the quality of health care and its continuity and availability will be an important factor in deciding whether a particular school is appropriate for an individual child with special needs.
15.19 Health services to non-maintained special schools may be provided by area health authorities on request, and when resources permit. Independent schools catering wholly or mainly for handicapped pupils, however, are not in receipt of national health services, but they may provide adequate health services themselves. We believe that health services to both types of school should be similar in scope and scale to those available in maintained special schools. Non-maintained special schools should ask area health authorities for specialist health services and authorities should supply them. Independent schools catering wholly or mainly for handicapped pupils should request and pay for such services. The availability and level of such services should be important
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criteria for decisions by local education authorities as to whether to use a particular school for an individual child. We recommend that local education authorities, in consultation with area health authorities, should satisfy themselves that adequate health care is available before placing children in non-maintained special schools or independent schools catering wholly or mainly for handicapped pupils.
15.20 Our enquiries about arrangements for young people over 16 with special needs suggest that health services do not always cover satisfactorily the transition from school to further or higher education and training, or the discovery and assessment of special educational needs which may arise at this stage. The transfer to work from school is also not normally accompanied by continued medical surveillance although, as we indicated in Chapter 10 (paragraph 10.102), one of the functions of the Employment Medical Advisory Service is to provide occupational health guidance during this period and thereafter. We believe, as we indicated in that chapter, that the Specialist in Community Medicine (Child Health) should ensure that major responsibility for the health of young people with special needs, particularly those with more severe disabilities, during the transition to early adulthood is clearly assigned before the end of their formal education. We therefore recommend that the Specialist in Community Medicine (Child Health) should ensure that arrangements are made for the transfer of responsibility for the medical surveillance of a young person with special educational needs to an appropriate branch of the health service when that young person leaves school or further education. We make this recommendation in the knowledge that the Court Committee referred consideration of this matter to us, and that the recommendation will have resource implications. We recognise that district handicap teams may also play an important part in these transitional arrangements.
15.21 Local education authorities and educational institutions have been urged to consult area health authorities and family practitioner committees about arrangements to assist students to use national health service facilities if they need them. (10) Clearly students with more severe or complex disabilities or disorders will continue to need health service support, and it is important that it should be readily available. We therefore recommend that health services comparable to those provided for special schools should be made available to establishments of further or higher education which cater for students with more severe disabilities or disorders.
15.22 We now turn to arrangements for the assessment of the special needs of those children with particularly rare or complex disabilities and for their support. We are pleased to note that the principle of the establishment of district handicap teams has been accepted by the Secretary of State for Social Services. The Circular advising health authorities of the government's conclusions on the recommendations of the Court Report indicates that such teams should provide a framework within which all the needs of the relatively few children with severe disabilities, physical, sensory and mental, can be met, including their
(10) DES FECL 5/76, DHSS HN(76)173, Health services for students on full-time and sandwich courses (30 September 1976).
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needs for psychological and psychiatric help. (11) There are already in existence child guidance and child psychiatric teams concerned with the assessment and treatment of a wide range of learning, emotional and behavioural disorders. These operate in parallel with district handicap teams. The membership of these different teams as well as some of their functions often overlap, as we indicated in Chapter 4 (paragraph 4.44). There is therefore a need for discussion at local level regarding the interaction and relationship between the various assessment teams, and the way in which the needs of the children with more severe disabilities or disorders seen by the child guidance team can be met.
The role of different specialisms and professions
15.23 We turn now to the work of different members of the health service. Our list is not exhaustive, nor is it intended to diminish the contribution of those not mentioned, some of whose functions have been discussed earlier in this report. Physiotherapists, speech therapists, occupational therapists and nurses may all contribute with doctors and teachers to a programme of treatment and education. Where each profession works in isolation programmes will be uncoordinated, ineffective and uneconomical in the use of professional time. We have observed in special schools and elsewhere the importance of well-planned teamwork within which each specialist contribution is enhanced by co-operation with and reinforcement from others. We hope that these patterns of working will become more common.
Paediatricians and clinical medical officers
15.24 The former school medical officers were transferred to the national health service, on reorganisation of the health service, as clinical medical officers and senior clinical medical officers. They have always had a vital role to play in the identification, assessment and follow-up of children with special needs; and in giving advice to parents, teachers and others about such children. We therefore welcome the assurance of the Secretary of State for Social Services in his statement on 27 January 1978 that there is an important long-term future for these doctors as an integral part of child health services. We also welcome his endorsement of the need to increase the extension of specialist paediatric services into the community, as an essential contribution to the successful development of services for ordinary and special schools and for district handicap teams. These doctors must work closely together, and with other members of their own profession as well as those of other disciplines, in order to ensure the effective delivery of services.
Child and adolescent psychiatrists
15.25 Although we suggested in Chapter 14 that educational psychologists should remain foremost in the assessment and management of behavioural and emotional problems which present themselves in schools, the child psychiatrist will have a vitally important part to play when such difficulties arise. Severe problems, especially when they may indicate some form of mental illness or
(11) DHSS Health Circular HC(78)5. Local Authority Circular LAC(78)2, Welsh Office Circular WHC(78)4, op. cit.
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unusually serious emotional disturbance in the child or his parents, will need to be referred to psychiatric services for further investigation. The psychiatrist's medical background will be of particular value when physical symptoms arise that are not organically determined and essential when the use of drugs in treatment is under consideration. His contribution however will by no means be limited to such cases. He will often need to consult the school when he is dealing with children initially referred by general practitioners because of problems arising within the home. Indeed it is desirable that at least some members of child guidance teams apart from psychologists should have regular contact with teachers, if possible in the school setting. Such contacts already exist in many cases and are particularly necessary in special schools for maladjusted children or schools taking a high proportion of such children. It would be desirable for this practice to be extended to ordinary schools. In some schools for maladjusted children the staff feel a need for regular discussion with someone less intimately involved in the school of the feelings aroused in them by particular children and of techniques for managing the pupils' behaviour. A psychiatrist, social worker or psychologist may be a suitable person for this task, but whoever undertakes it will need special skills for the purpose.
15.26 The skills of the child and adolescent psychiatrist will often be required for the multi-professional assessment of special needs. For this reason the psychiatrist, if not a member of the district handicap team, should be readily available to participate in assessment. Special expertise is required for the psychiatric assessment and management of children currently described as mentally handicapped. In some areas the child psychiatrist will be trained and experienced to deal with children of all ranges of ability, whereas in others a psychiatric specialist in mental handicap, including mental handicap in children, will have this responsibility. Finally, we have been made aware of the current dearth of psychiatric services in many respects, in particular the lack of facilities for adolescents, especially hospital units for very disturbed young people. We hope that these services will be increased as soon as possible.
Dental services
15.27 Children with disabilities may have special dental needs which call for special dental arrangements. Moreover, orthodontic treatment may have educational implications. The Area Dental Officer is responsible for seeing that the necessary professional advice and arrangements for treatment are available. As with other branches of the health service, not every practitioner will have knowledge and experience of children with disabilities and the Area Dental Officer will need to ensure that the necessary provision is made to meet special needs. Dental services for children with disabilities and significant difficulties in ordinary and special schools need to be further developed.
Nurses
15.28 The Area Nurse (Child Health) has responsibility for ensuring, in consultation with the local education authority, that nursing services are provided for ordinary and special schools within the area. We are aware that the wide-ranging duties of the Area Nurse (Child Health) are difficult to carry out in the existing management structure of the area nursing services. The contribu-
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tion of health visitors was discussed at length in Chapters 4 and 5. We outlined in Chapter 5 an important function which we consider health visitors should assume, namely that of acting as the Named Person to whom parents of children with special needs below school age can turn for information and advice. We welcome the increase in health visitors for England proposed by the government in the period up to 1980-81 (12) and urge that the issues raised in this report should be given due weight in the future development of the health visiting service. The health visitor, with additional training in the needs of children with disabilities and significant delays in development, has a crucial part to play in ensuring that early special help is available to parents and children, and by so doing limiting the effects of such disabilities on the child's subsequent development. Close relationships with the local education authority will clearly be very important in ensuring that all the necessary elements of that special help are provided.
15.29 We now turn to the contribution of the school nurses who will normally work with health visitors. The school nurse in both ordinary and special schools can play a very important part in the discovery and support of children with special needs. In ordinary schools, part of the school nurse's task is both to inform the health service of needs detected by the school and to ensure that teachers have the necessary information about individual children. Her function in providing health care for children in ordinary schools is particularly important as far as those children with special needs are concerned, and will assume increased importance as Section 10 of the Education Act 1976 is progressively implemented. Similarly her contribution to health education may be expected to increase in future. For these reasons we see the provision of adequate nursing services to ordinary schools as essential. As we mentioned in Chapter 8, a recent survey of nursing care in special schools found wide variations in the service provided from one area health authority to another. (13) We consider that in day special schools the level of staffing required should normally be determined by the nature and degree of the children's special needs rather than the particular disability or disabilities for which the school caters. In boarding special schools, particularly for children with physical disabilities, nursing arrangements need to be very closely coordinated with those for child care. We foresee that the proportion of pupils in special schools with severe and complex disabilities will increase, and for this reason we regard it as essential that adequate numbers of appropriately trained and experienced nurses should be available to work in special schools. We welcome the recognition by the Secretary of State for Social Services in his statement on 27 January 1978 of the need to establish a national training scheme for school nurses.
15.30 Hospital schools and other educational arrangements in hospitals also bring nurses and teachers into partnership in meeting children's needs. In hospitals for the mentally handicapped programmes for individual children are most successful when nurses and teachers adopt a common approach and reinforce each other's efforts. In units for children who are disturbed or who have psychiatric disorders, too, the work of nurses and teachers needs to be complementary. We recognise that both nurses and teachers need additional training
(12) Priorities in the Health and Social Services. The Way Forward (HMSO 1977) p.10.
(13) DHSS Circular CNO(78)1, Provision of Nursing Care in Special Schools (9 January 1978).
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to work in such units and it is our view that shared arrangements for in-service training should be developed.
Speech therapists
15.31 The work and training of speech therapists have recently been reviewed by the Quirk Committee. (14) We have observed their work only in the context of assessment services and special schools but we recognise the valuable contribution which they make to the speech and language development of many children with different disabilities and difficulties. We have been particularly impressed by the very considerable contribution made by speech therapists in recent years to the teaching of non-communicating children, in the course of which they have used supplementary forms of communication. The survey undertaken for us of teachers' views and attitudes in both ordinary and special schools revealed the strong need felt by many teachers for more contact with speech therapists. (15) There is an urgent need for more speech therapists and in particular for better speech therapy services to ordinary schools. We would welcome the development of courses which lead to the dual qualification of teacher and speech therapist. The contribution of speech therapists is enhanced when they work closely with teachers and child care workers as well as parents so that their special help is supplemented by regular practice in everyday settings. We also commend those arrangements in which speech therapists in special schools and units contribute to programmes worked out by a multi-professional team.
Physiotherapists
15.32 The contribution made by physiotherapists to the assessment and development of the physical skills and mobility of children with special educational needs is widely acknowledged. In special schools and in ordinary schools where there are groups of children with physical disabilities, their services are needed to provide treatment and to assist in the development of physical education programmes and work with individual children. We have visited schools where physiotherapists have carried out successful work in classrooms with teachers and where teachers and aides have been enabled to supplement and complement their work. The way in which the professional skills of physiotherapists, remedial gymnasts, teachers and others are shared in the interests of promoting the development of children including those who are physically handicapped, those currently described as mentally handicapped and others with motor and spatial problems seems to us a highly valuable development.
Occupational therapists
15.33 Some occupational therapists who work with children and young people with disabilities are employed by the health service and others by local authority social services departments. Their work with children under five, with pupils in special schools and with young people over 16 has commonly taken the form of giving advice to the professionals engaged in meeting their needs and
(14) Speech Therapy Services Report of the Committee appointed by the Secretaries of State for Education and Science, for the Social Services, for Scotland and for Wales in July 1969 (HMSO 1972).
(15) For details of the survey see Appendix 8.
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of training the children and young people to overcome physical disabilities in the activities of daily living and in recreational pursuits. In these and some other fields, for example work with the mentally handicapped and the emotionally disturbed, their contribution in collaboration with teachers, health visitors, nurses and child care staff can be significant. We see the need for an increasing use of their services to enable young people with disabilities or significant difficulties to lead as independent a life as possible.
The training of members of the health service concerned with children with special needs
15.34 It is not within our remit to comment in detail on the supply and training of members of the health service. In a number of chapters in this report, however, we have drawn attention to the additional training required to work with children with special needs. A considerable amount of attention is currently being given to the training of doctors, health visitors and school nurses as a consequence of the Court Report. We hope that our findings will be taken into account. We consider that training for work with children with special needs should be conducted through post-qualification in-service courses organised wherever possible on an inter-professional basis. These should be of a general nature for some professionals and of specific relevance to different areas of disability for others, particularly doctors, nurses and therapists working in special schools and units of different kinds. Post-graduate medical centres throughout the country could, in our view, make an important contribution to the post-qualification training of doctors, nurses and other professionals in this field. We therefore recommend that more opportunities for post-qualification training on an inter-professional basis should be made available to members of the health service concerned with children with disabilities and significant difficulties.
Future developments
15.35 The increasing trend towards the provision of special education for children with more complex and severe disabilities in ordinary classes and in special units in ordinary schools will have significant implications for the provision of health services to ordinary schools. It is essential that the health services provided should be of the same quality as those available to special schools and that there should be scope for a multi-professional approach to work with children. We recognise the danger of dispersing scarce health service resources and, as we pointed out in Chapter 7, envisage that it will in some cases be necessary to concentrate certain special classes and the related provision of therapy and treatment at particular schools. Nevertheless, a wider delivery of health services will be essential to the extension of special educational provision in ordinary schools. Area health authorities and local education authorities must jointly plan arrangements for special educational provision in ordinary schools which will guarantee that adequate health services beyond those which would normally be available will be provided. Later in this chapter we recommend that they should be advised by the Joint Consultative Committees on the services that will be required.
15.36 The decrease in the school population which will occur in the next few years may encourage some area health authorities to consider a reduction in the
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resources devoted to child health services. There are however many aspects of the services which need strengthening and we would emphasise that the opportunity provided by the falling school population should be used to secure the developments proposed in this report.
II THE PERSONAL SOCIAL SERVICES
15.37 Local authority departments of social services (social work departments in Scotland) are of comparatively recent origin, although the concern of local authorities for the social problems of handicapped children and young people has a much longer history. The Kilbrandon Report in 1964 laid the foundation for the formation of social work departments in 1968. (16) The Seebohm Report in 1968 led to broadly similar arrangements in England and Wales in 1970, (17) (though the two reports were acted on differently in their respective countries). The powers of local authorities in relation to handicapped children are defined in the National Assistance Act 1948, the Health and Public Services Act 1968, the Social Work (Scotland) Act 1968 and the Chronically Sick and Disabled Persons Act 1970. The Children Acts of 1948; 1963 and 1975 and the Children and Young Persons Act of 1969 also have a bearing on their duties in this respect. Social services departments now carry out the social service duties of local authorities in respect of families and most children with disabilities or significant difficulties, especially those living in a seriously deprived environment.
15.38 Social services departments now provide a wide range of facilities and specialist staff. Since the National Health Service Reorganisation Act in 1973, which brought hospital-based social workers into social services departments, all social workers employed by health and social services have been based in the same department. In the last chapter we discussed some duties of social workers with regard to school-based work. The contribution of some social workers was also considered in Chapter 10 in the context of services for young people with disabilities and significant difficulties over the age of 16. Many of the services discussed in that chapter are equally important for younger children with disabilities and for their families, particularly those children living in circumstances that may be disadvantageous to their development. In this chapter we deal with various aspects of the work of social services departments and with the contributions of some of those who work in them as they relate to the special educational needs of the children and young people who are our concern.
15.39 There is almost certainly family and social stress where children with special educational needs are living at home. Indeed the problems of such children and their families may have far-reaching social implications. We are in no doubt that the support and advice provided by social services departments in a variety of ways, is an essential component of the services we wish to see developed for children with special educational needs. Ideally social services departments should be able to work with all the families of the children who, in our view, are likely to require some form of special educational provision. In practice, however, they will normally be concerned, in the educational
(16) Children and Young Persons, Scotland Report by the Committee appointed by the Secretary of State for Scotland. Cmnd 2306 (HMSO 1964).
(17) Report of the Committee on Local Authority and Allied Personal Social Services. Cmnd 3703 (HMSO 1968).
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context, with those children who are recorded by the local education authority as requiring such provision, but any parents of children with special educational needs should be able to seek and receive their help and support should they wish to do so.
15.40 Throughout this report we have had regard to the contribution of social services departments to assessment, support for families and provision for children and young adults with special needs. We have discussed in Chapters 8 and 10 the educational component of the work of community homes and adult training centres. We also recognise the contribution of the staffs of day nurseries, residential homes and day centres, in collaboration with social workers specialising in work with different disabilities and other specialists, to meeting the needs of the children with whom we are concerned and of their families. In the following paragraphs we consider a number of particular issues concerning the work of social services departments in relation to education departments, without attempting a comprehensive review of social services for children and young people with disabilities.
Discovery, assessment and support
15.41 The staffs of day nurseries, those running playgroups and child minders may be the first people outside the family to see signs of special educational needs in children. As we explained in Chapter 5 their awareness of special needs may be vital if children are to receive the help they need, and our comments in the last chapter on the need for training opportunities for nursery nurses apply equally to these staff. The staff of social services departments responsible for the registration of child minders and playgroups and those who work with them from the education, health and social services should ensure that appropriate advice and support is available. We are aware that there are many problems in achieving this aim at present. As the research undertaken for us by Dr Clark indicated, a significant proportion of children in playgroups and day nurseries have recognisable special needs which are not being met by the normal programmes. (18) Staff in playgroups and day nurseries thus need knowledge and understanding of special educational needs and the services available to meet them as we stressed in the last chapter. So, too, do any social workers designated by the multi-professional team to act as Named Person for the parents of young children assessed by the team as requiring special educational provision. We consider their need for training further in a later section of this chapter.
15.42 When children or young people at any stage of their education are thought to have special needs which require assessment, the contribution of social workers will in many instances be of considerable importance. We hope that the ordinary school will have a sufficiently close relationship with the locally based social work team for any necessary information about a child's social background to be readily available to the school for the purposes of school-based assessment, though we recognise that this is not always the case at present. We discussed the need for close links between social workers and schools
(18) For details of the research project see Appendix 6.
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in Chapter 14. The school should look to the social worker for help at Stage 3 where this is appropriate. We recommended in Chapter 4 that social services departments should always be informed of the referral of children for assessment at Stage 4 or 5 so that they can make a contribution if they wish to do so. They should also be informed of the decision by a local education authority to record a child as requiring special educational provision, so that they can make social service support available if required by the family.
15.43 In our view social services departments should accept that they have a major responsibility for providing support at the stage when young people with special needs move from school to further education, work or other arrangements within the community. Unless the continuing support of social services departments is available, the future development of some young people with disabilities may be in jeopardy and those with more profound disabilities may have no alternative to placement in hospital. We discussed these matters more fully in Chapter 10. The involvement of social workers in the process of reassessment, to be carried out under our proposals at least two years before a young person with special needs is due to leave school, should result in an early intimation of the young person's future needs for social service support. These may include the provision of occupational therapy, of special aids and equipment and adaptations to living arrangements. Close collaboration between social workers and specialist careers officers is also, in our view, essential. We recommend that social services departments should nominate a senior social worker to act as a liaison officer with the careers service and the specialist careers officer.
Children in care
15.44 We recognise that the circumstances which may lead to children being taken into care by local authorities are also likely in many instances to give rise to learning and behavioural difficulties. Any assessment made under the aegis of social services departments should therefore in our view always include consideration of special educational needs and, where necessary, arrangements should be made for the children to be recorded by the local education authority as requiring special educational provision. We regard it as essential that when children with special educational needs are placed in foster homes or community homes or moved from one home to another, account should always be taken of the availability of suitable educational provision in the vicinity and there should be close collaboration between education and social services departments. It is equally important that any special educational arrangements made in independent boarding schools should be known to be appropriate and that such schools should not be used by social services departments without the agreement of the local education authority, as we recommended in Chapter 8.
15.45 In Chapter 8 we mentioned the needs of children with disabilities who spend long periods in hospital. The trend to make more provision in the community for these and other children who require long-term residential care is one which we support, provided that adequate resources are made available. Such care may be provided in a variety of ways, for example in foster homes. Some hospitals provide short-term residential care to relieve parents from stress and we emphasised the need for this form of help in Chapter 9. We consider
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however that it is preferable for such short-term residential arrangements to be made in the community without interrupting the child's normal pattern of schooling and that social services departments should assume responsibility for making such arrangements.
15.46 The planning and running of community homes without education on the premises (children's homes in Scotland) should be discussed regularly with local education authorities to ensure that suitable provision is available in local schools for children in the homes who have special educational needs. Moreover, good relations should be fostered between residential social work staff in the homes and teachers in the schools which the children attend. Without good relations between community homes and schools there is a very real danger that the social and educational needs of the children concerned will be considered in isolation from each other and inadequately met. For some children, child care staff may be substitute parents and in our view all that has been said elsewhere in this report about the needs and contribution of parents applies equally to them. The provision of education in community homes with education on the premises was discussed in Chapter 8, where we recommended that teachers working in such homes should be employed by local education authorities and seconded to social services departments.
Adult training centres for the mentally handicapped and day centres for the physically disabled
15.47 The staffing of adult training centres and day centres, to which many young people with severe disabilities proceed on leaving special schools, forms a major part of the responsibilities of social services departments. In our view those staff working with handicapped young people in adult training centres and day centres need specific training for the purpose. We recognise the initiatives taken by the National Development Group for the Mentally Handicapped as outlined in their recent pamphlet, (19) in which they proposed that education in its broadest sense should be provided in adult training centres and that these should in future be known as social education centres. The developments in Scotland have been influenced by the Melville Report. (20) The evidence submitted to us and our own visits suggest that it is important that arrangements for the education and training of young adults in adult training centres and day centres should be separate from those for older people, since it may be possible for the young people to make considerable progress if a special programme is developed for them. It is undesirable in our view that young people entering adult training centres or day centres should be admitted to and retained in age groups ranging from 16 to 60 plus. We therefore recommend that separate provision and a differentiated programme of education and other activities including training should be available for young people in adult training centres and day centres or elsewhere. We have already recommended in Chapter 10 that the educational element in any programme should be provided by local education authorities. The staff of adult training centres and day centres where young people are admitted direct from
(19) Day Services for Mentally Handicapped Adults National Development Group for the Mentally Handicapped. Pamphlet Number 5 (July 1977).
(20) The Training of Staff for Centres for the Mentally Handicapped Report of the Committee appointed by the Secretary of State for Scotland (HMSO 1973).
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school need to be familiar with the special schools in the area. They should be encouraged by social services departments to visit the schools and take part in discussions with the staff in order to facilitate the transition of the young people from the school to the centre. For their part, teachers in special schools should be encouraged to visit the training or day centres.
Training
15.48 Training in dealing with the particular problems of children and young people with special educational needs is as necessary for workers in social services departments as for members of other services. We therefore recommend that an element should be included in the initial training of all social workers and residential child care staff which acquaints them not only with the social work aspects of different disabilities but with the special education services available to children and parents. Further training is also needed for some social workers to deal with the problems associated with particular disabilities, for example deafness or psychiatric disorders, and we hope that the Central Council for Education and Training in Social Work will take steps to see that such training is provided. Misunderstandings sometimes occur between teachers and social workers simply because of a lack of knowledge of each other's work, and inter-professional training is one way of overcoming them. We urge local authority education and social services departments to place much greater emphasis on the provision of joint in-service training for teachers and social workers.
III JOINT CONSULTATIVE COMMITTEES
15.49 As we have already indicated, the needs of children and young people with disabilities and significant difficulties are the common concern of health, education and social services, which have overlapping responsibilities. The National Health Service Reorganisation Act 1973 set up statutory bodies, known as Joint Consultative Committees, to consider and advise the three services on the planning, provision and coordination of arrangements in their areas. Membership of these Committees is drawn from the appointed members of the area health authority and elected members of the local authority, some of whom are members of education and social services committees. Some Committees now include officers of health, education and social services, while others appoint sub-committees of officers to study specific problems. Where the boundary of the area health authority is not coterminous with that of the local authority, it is of course necessary for the latter to have relations with more than one Joint Consultative Committee, with the result that there may be variations in the recommendations made for different parts of a local authority's area. Notwithstanding this problem, we regard the work of Joint Consultative Committees as vital for the coordination and development of services for children and young people with disabilities or significant difficulties, and in the next chapter we consider how their influence might be increased. We welcome and endorse the point made by the Secretary of State for Social Services in his statement on the Court Report on 27 January 1978 that Joint Consultative Committees should be the forum in which concentrated local effort should be planned.
15.50 The National Health Service (Scotland) Act 1972, while laying on health boards, local authorities and education authorities a duty to co-operate with
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one another, did not provide for the establishment of statutory joint committees. The recent Report of the Working Party on relationships between health boards and local authorities, (21) however, recommended the establishment of Joint Liaison Committees. Health boards and local authorities have been urged to implement this recommendation wherever arrangements for such committees do not already exist.
15.51 There is one aspect of the work of Joint Consultative Committees which we wish to emphasise in this chapter. The provision of health and social services to ordinary and special schools is, as we have indicated, central to the development of special education, particularly when increased provision is to be made for children with disabilities in ordinary schools. We regard the Joint Consultative Committees as having a crucial part to play in advising their constituent authorities on the degree of dispersal of health and social services compatible with effective support for children with special needs in ordinary schools. Thus they will be one important influence in determining the rate at which it will be practicable to implement Section 10 of the Education Act 1976. We recommend that Joint Consultative Committees should be asked to advise health, education and social services authorities as soon as possible on the health and social services which will be needed by and can be provided for ordinary schools to meet the needs of increasing numbers of children with disabilities or significant difficulties, and what priority their provision should be accorded. We hope that when Joint Liaison Committees are set up in Scotland they will give priority to this task.
CONCLUSION
15.52 In this chapter we have discussed some aspects of the work of health and social services in relation to educational provision for children and young people with special needs. It is, we believe, evident throughout our report that children with special educational needs are often the concern of other services besides education and that a coordinated approach to their problems is essential at all levels. Where they are effective, Joint Consultative Committees (and in Scotland Joint Liaison Committees) can play a significant part in influencing the provision of different services within a local authority area. They can also stimulate arrangements for in-service training on an inter-professional basis. However, it is at the level of the individual doctor, teacher, nurse, social worker or other professional that the ideas of collaboration and joint working advanced in this report must be put into practice. The effectiveness of joint working arrangements for children with disabilities and difficulties will depend on all concerned being well informed and aware of each other's work and able to develop the means to deal with common problems.
(21) Working Party on Relationships between Health Boards and Local Authorities - Report (HMSO 1977).
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CHAPTER 16: RELATIONS BETWEEN PROFESSIONALS, CONFIDENTIALITY AND CO-ORDINATION OF SERVICES
INTRODUCTION
16.1 The development of close working relations between professionals in the different services concerned with children and young people with special needs is central to many of the recommendations in this report. In particular, it is a prerequisite of the effectiveness of our proposed procedures for assessment and of provision for children with special educational needs whether in ordinary or special schools. We recognise that the development of such relations is necessarily a slow process, depending as it does on the establishment of trust between different professionals and understanding of each other's functions. This process can, however, be facilitated in various ways, particularly by the development of good practice in the sharing of information and by the provision of opportunities for members of different professions to take courses of training together. In this chapter we consider aspects of the communication of information and of inter-professional training. We also make proposals for formal machinery for co-ordinating services at different levels, since such machinery, though not sufficient in itself, can help to provide a framework within which relations between different professions can develop effectively.
I THE DISSEMINATION OF INFORMATION
16.2 It was widely argued in the evidence submitted to us that information is often not shared between doctors, nurses, psychologists, teachers and social workers, and that in the interests of individual children it should be. The inadequate communication of information both between and within different professions and between professionals and parents also emerged very clearly from the report of the research project on services for parents of handicapped children under five which was undertaken on our behalf by a team under the co-direction of Professor Chazan and Dr Laing of the University College of Swansea. (1)
16.3 We concur with the view expressed in evidence that information should be shared between those professionals concerned with meeting the special needs of a particular child. We emp