Integrated commissioning strategy for children and young people’s Special Educational Needs and Disabilities (SEND) services in Lincolnshire

Introduction

This strategy is dynamic with regular review for accuracy

The Health and Care Act 2022 reformed the National Health Service (NHS), social care and public health.

The main purpose of the act is to establish a legislative framework that supports collaboration and partnership-working to integrate services for patients.

The act includes changes to public health, social care and the oversight of quality and safety.

The aims are to make the health and care system (the system) less bureaucratic, more accountable, and more joined up.

The integrated care system (ICS) was created with integrated care boards (ICB) to formalise joint commissioning of local NHS services alongside the local authority.

Joint commissioning for children and young people (CYP) services is well-established in Lincolnshire, building on the partnership principles as set out in the National Health Service Act 2006 section 75 and section 76, as well as the Children Act 2004, Children and Families Act 2014, SEND Code of Practice 2015, National Institute for Health and Care Excellence - NICE Guidelines [NG43] 2016 and Equality Act 2010.

Lincolnshire has ambitions to further integrate the commissioning of services that will improve the lives of residents.

This strategy outlines these ambitions specifically for Lincolnshire CYP aged 0–25 years with SEND.

Lincolnshire’s shared ambitions and objectives for CYP with SEND

Lincolnshire County Council’s children’s services vision is: “putting children first – everyone working together for all children, young people and families to be happy, healthy, safe and the best they can be.”

Lincolnshire County Council (LCC), Lincolnshire ICB and Lincolnshire Parent Carer Forum (LPCF) have jointly developed and are committed to this strategy.

The strategy reflects the shared ambition of all partners to work together to improve support pathways and outcomes for Lincolnshire CYP with SEND to ensure they have the best possible start in life.

It also ensures they have the right support through all stages of development and in preparation for adulthood, whilst at the same time making best use of all resources. This can only be achieved through a strong integrated approach.

Inclusive aims are:

to remove any barriers and reduce inequalities that CYP with SEND may experience compared to their peers so they can receive the right support, in the right place, from the right people at the right time, as close to home as possible
to help CYP, parent or carers and professionals to understand in a clear way what support is available, including support that can be self-accessed
to ensure education settings have expert knowledge and understanding of how best to support and meet CYP’s additional educational needs, making necessary reasonable adjustments where required. Settings and families should work together to ensure consistency in the home environment and education setting
to reduce education exclusions of CYP with SEND; to recognise behaviour is a communication of need and that CYP may need multi-service support wrapped around them to meet their needs in an inclusive way
to have high aspirations for CYP with SEND and help them to achieve academically, have personal resilience, develop social connections and live as independently as possible

Shared objectives are:

to have an accurate and shared understanding of the needs of Lincolnshire CYP
to engage CYP with SEND and their families, and professionals from all relevant sectors in the co-production of service design, development and evaluation
to improve joint working between organisations, with local leaders coming together to agree a shared vision and priorities
to clarify current resources, financial and other, across the system and identify if there are better ways to integrate or maximise resources to improve outcomes for CYP with SEND
to champion investment in support that will improve outcomes for CYP with SEND
to provide a single point of access for CYP, families and professionals to clear information that will support CYP with SEND
to reduce the number of families seeking mediation services and escalation to tribunal by providing clearer information about the SEND system and helping CYP get the support they need
to improve information and data sharing across organisations to prevent CYP and families from having to explain their need multiple times
to improve transition between stages in education, different services, and in particular from children’s to adult services, where applicable
to improve the offer of community based support by increasing SEND training for nursery and school staff, commissioned and voluntary sector community groups
to reduce or remove organisational barriers such as poor communication, lack of consistency, IT etc

What is integrated commissioning for SEND?

Integrated commissioning for SEND is when partners come together to commission services which are then provided across the system for service users with additional education, health and or care needs (EHC).

The two lead commissioning organisations in Lincolnshire are LCC and Lincolnshire’s ICB; working in partnership to actively seek opportunities to jointly commission services where there is benefit.

Organisations may retain their own commissioning responsibility and may operate to different commissioning rules, but they can consider sharing resources to develop a comprehensive, consistent approach to understanding needs, agreeing priorities, designing, procuring, monitoring, and managing the performance and quality of services.

Co-production with CYP and their families, alongside meaningful consultation with schools and providers from across the system, is critical in creating effective integrated solutions. This shared commitment reduces duplication of services and resource, promoting jointly agreed priorities ensuring the most effective use of public funds, services and support for CYP and their families.

The commissioning cycle as set out in the SEND code of practice has five clear stages that structure how local partners should commission services to meet local needs and support better outcomes.

The commissioning cycle

The five stages on how partners should commission services are:
establish partnerships: across education, health and care and with parent groups, children and young people

joint understanding
joint planning
joint delivery
joint review to improve service offer

The cycle through its simple structure helps guide how partners should develop a joint understanding of the outcomes that their local population of CYP with SEND aspires to.

Lincolnshire integrated commissioning arrangements for CYP with SEND

integrated system governance

The ICP is the primary board advised and governed by the health and wellbeing board with full oversight of the integrated care system alongside the CYP ICB.

The CYP integrated transformation board (ITB) brings together the work of a number of system partners across LCC and NHS, namely: United Lincolnshire Hospital Trust (UHLT), Lincolnshire Partnership Foundation Trust (LPFT), Lincolnshire Community Health Services (LCHS), the CYP integrated commissioning steering group, Core20Plus5, SEND health committee and the SEND steering group, as well as being supported by organisational boards and various system groups working together, covering different aspects of health care services including: Better Lives Lincolnshire executive team, local maternity and neonatal system and the mental health, dementia, learning disability and autism executive group, and the NHSE regional CYP board.

Integrated Care Board (ICB)

The ICB is a statutory body in place since 1st July 2022. Its general function is to arrange provision of services for the purposes of the health service in England in accordance with the Health and Care Act 2022.

Lincolnshire has a board-level executive lead for CYP with SEND, a designated clinical officer (DCO) for SEND since 2017, and an associate DCO since 2019; working in partnership with LCC’s SEND service, supporting the ICB to ensure it performs its functions effectively for CYP with SEND and their families.

The ICB will use its resources and powers to achieve demonstrable progress, collaborating to tackle complex challenges, including:

improving the health of CYP
supporting people to stay well and independent
acting sooner to help those with preventable conditions
supporting those with long-term conditions or mental health issues
caring for those with multiple needs as populations age
getting the best from collective resources so people get care as quickly as possible

CYP Integrated Transformation Board (ITB)

The ITB is co-chaired by the ICB associate director of nursing and quality and the LCC assistant director for children’s health and commissioning.

The purpose of the ITB is to provide strategic oversight of CYP services in Lincolnshire with the aim of transforming pathways across health and care incorporating education.

The board meets bi-monthly and provides strategic oversight of CYP services in Lincolnshire, bringing together representatives from across the system, including those with a lived experience, to jointly plan and prioritise services and support for CYP, and to provide updates on services, work programmes and flag any risks and issues.

All members of the ITB, including the DCO for SEND, children’s head of service for SEND and LPCF, have an equal voice and opportunity to review how current service provision and future planned arrangements could be improved and delivered more efficiently with better outcomes for CYP through improved integrated working.

The ITB in turn, provides updates to NHS England (NHSE) regional group. Formal governance and decision making is in line with each partner’s own decision-making process.

Children’s integrated commissioning team (CICT)

The ICB and LCC jointly fund the CICT. The work of the team is directed by the CYP integrated commissioning steering group co-chaired by ICB deputy director of nursing and quality and LCC head of children’s strategic commissioning.

CICT work is aligned to priorities identified through the ITB. Steering group members come together to:

determine the scope of jointly agreed projects
identify cross-cutting interdependencies
agree timelines
determine who is responsible for delivery from across ICB, LCC CYP commissioners, or the CICT

The ICB and LCC work closely together to ensure a consistent, countywide commissioning approach thus preventing duplication of work and service delivery.

The work of the CICT is determined by listening to CYP and families, partners, joint strategic discussion, local and national intelligence, and evidence of need reported within up-to-date local strategies including:

Lincolnshire’s integrated commissioning key achievements

following Lincolnshire ICB’s stage 7 maturity matrix submission to NHSE at the end of 2023, Lincolnshire is the only area rated green, good overall for ICB SEND maturity across the 11 ICS within the midlands region
there is strong and close working with Lincolnshire Parent Carer Forum (LPCF) as strategic partners; ensuring user experience helps shape and inform co-production of current service delivery and future planning of system developments
LCC commission a well-informed Liaise - Lincolnshire’s SEND information, advice and support service (SENDIASS) sits at arms length to the local authority and health services, trained in SEN and disability law, working to national minimum standards. Liaise provide confidential and impartial information, advice and support to CYP with SEND and their parents or carers
LCC children's strategic commissioning service work to ensure providers comply with the SEND code of practice and Children and Families Act 2014, including keeping the SEND local offer updated with their service information
LCC has been the provider of the children’s 0-19 health service since 2017; funded through the public health grant. Health service locality teams work alongside early help, social workers and midwifery services. Delivery includes a specialist CYP community continence service commissioned by the ICB
Lincolnshire has protected its 48 children’s centres, delivering a number of services to support CYP with SEND in their early years including:
- best start Lincolnshire early years services; with a focus on inclusive early learning activities
- early support learning provision; specialist support and a short break specifically for children with disabilities (CWD) and their families
- early years locality team practitioners
ten children’s centres are also designated family hubs providing universal and targeted support for CYP and families
family hubs’ funding is being utilised to increase the capacity of the perinatal mental health peer support service, commissioned by the ICB, to support mild to moderate perinatal mental health concerns and increase the offer through the Lincolnshire recovery college. In addition, a parent-infant mental health project led by LPFT to work across Child and Adolescent Mental Health Services (CAMHS) and Healthy Minds Lincolnshire, in partnership with the council’s health visiting service and other relevant professionals, to determine, introduce and strengthen an enhanced offer for children up to the age of two years
children’s services are also utilising the family hubs’ funding to implement a speech and language pilot to provide early speech and language support by speech and language assistants for targeted work with Lincolnshire children aged three to four years
integrated commissioning arrangements are in place for extended communication and language provision (ECLIPS) to deliver enhanced plus (primary school element) and ECLIPS (secondary school and further education element) to support development of CYP speech, language and communication needs
the package of specialist online information and support workshops for families and professionals to better support CYP with sensory processing difficulties (SPD) has been extended with further developments continuing over 2024
integrated commissioning arrangements are in place to provide specialist nurse training for education settings, transport providers and short breaks’ staff for CWD
LCC and the ICB have pooled funding arrangements in place to support CWD in short breaks residential care
Lincolnshire has well established, multi-agency processes and partnership working in regard to monitoring autistic CYP or those with LD who are at risk of being admitted to a specialist mental health or LD hospital
LPFT provides management of an all-age dynamic support register (DSR) on behalf of system partners, which is used to monitor actions being taken by partners involved in their health, education and social care to avoid admission under the Mental Health Act. Continuing escalation of their behaviours can trigger multi disciplinary team or care education treatment review (CETR) processes to review what more could be done as a system to avoid admission. Fortnightly meetings are held, including representatives across health, social care and SEND, to review CYP on the DSR
as at the end of November 2023, Lincolnshire had no admissions of autistic CYP or with LD since April 2023, and no inpatients since September 2023, against a trajectory of three
a CYP key-working offer went live in Lincolnshire from April 2023, providing support for autistic CYP or those with a learning disability (LD), who are at risk of being admitted into hospital. The service initially supported those aged up to 18 providing key-working support to more than 90% of eligible CYP in Lincolnshire. It recently expanded to the full offer, supporting young people aged 18-25. The service aims to give CYP and their families the right support at the right time, to ensure systems within the community are responsive to meet their needs in a personalised and holistic way
during 2022-23 and since April 2023, Lincolnshire has undertaken training and promotion of the DSR with mental health professionals, implementing the CYP key-working offer with improved multi-agency monitoring and processes in relation to CYP at risk or inpatient. It is calculated that eight CYP have avoided admission in quarter two, 2022-23; de-escalating DSR rating from red to green
LCC is delegated the lead commissioning function for CYP mental health services on behalf of the ICB; formal integrated commissioning arrangements have been in place for over 10 years. LPFT is rated outstanding by the care quality commission (CQC) for its specialist community mental health services for children and young people, and provide most mental health services for CYP funded through a pooled budget between the ICB and the council.
an all-age autism community support hub is currently being established and will start delivering support in 2024. The hub will provide support to the voluntary, community and social enterprise (VCSE) sector in Lincolnshire to strengthen, grow and develop more autism community support provision for CYP, adults and their families, regardless of diagnosis. They will also provide advice and signposting to people of all-age in Lincolnshire who are seeking support around autism
there is a joint programme of work supporting the transforming care programme for CYP with learning disabilities or autism who have a mental illness or whose behaviour challenges services, as well as joint process between mental health and social care, including reviewing and improving CETR and s117 aftercare processes
Lincolnshire schools forum continues to support the funding of the behaviour outreach support service (BOSS) and the autism and learning difficulties (ALD) service (also known as working together team) from the high needs block of the dedicated schools grant (DSG). Both services were recommissioned in September 2022 and have a strong focus on early intervention and prevention, building resilience across Lincolnshire mainstream schools; maintained and academies, increasing inclusion and promoting a collective responsibility to improving Lincolnshire pupils’ social, emotional wellbeing and mental health concerns. These services work as part of a child-centred, multi-disciplinary team approach in order to reduce the risk of behaviours escalating that may compromise pupils’ attendance and learning
there are fully embedded pathways in place within LCC future4me service to ensure priority access to the CYP complex needs service for 0-18 year olds in custody at time of writing their resettlement plans. The complex needs service brings together education, health and care professionals into one team discussion
LCC is lead commissioner on behalf of the East Midlands region for the SEND mediation advice, mediation and disagreement resolution contract. The DCO and LCC work closely with the contract provider to ensure joint arrangements include understanding of the legislative SEND EHC process, providing a statutory independent, unbiased and effective mediation service to support families as early as possible to resolve any disputes to prevent the need for escalation to tribunal
joint development work has taken place to ensure full NICE compliance of the 0-16 social communication pathway
full implementation of Lincolnshire young voices (LYV); a pan-disability participation group of young people with SEND who research and then act upon issues faced by Lincolnshire CYP with SEND. LYV is funded by LCC with their engagement activity funded by ICB. The group collaborates with services and organisations within multiple sectors across the system to raise awareness of SEND, improve service provision and inspire change. LYV are led by both LCC SEND team manager and ICB DCO for SEND, with two paid young people as co-chairs with a committee membership of around 15 young people who all have lived experience of SEND
LYV have created an award winning elearning programme for professionals working with CYP with SEND, called ”A rough guide to not putting your foot in it”. Launched in 2022, it won the national association of special educational needs award. The training is available on the Lincolnshire Safeguarding Childrens Partnership website

Integrated commissioning future priorities for CYP with SEND

Clinical intervention in schools review

Lincolnshire made a commitment in 2018 to invest £101m to create 527 additional places within 13 of its 17 special educational needs (SEN) schools. Planned school site construction and adaptions are now near completion. A key aim of this project is to enable a wider range of CYP with varying SEND to attend their nearest special school in the area where they live, rather than have to travel to a specialist school for specific needs further across the county or outside the county. high-level aims and objectives include:

ensure those with complex medical needs, or on long-term ventilation, can attend their local special school in a clinically safe way
provide a robust health offer to meet the needs of CYP with SEND in Lincolnshire’s ‘all needs’ special schools
give parents or carers the confidence their local special school can meet their CYP’s health needs
empower or upskill special school staff to feel confident in meeting these needs within all settings

CYP therapy review

Due to increased demand in the system, an urgent review of Lincolnshire’s SALT service shall take place early 2024 to reshape the service where necessary; to ensure CYP and their families are provided with the right level of support at the right time to meet their speech and language needs. A wider review will then recommend developments to create a more integrated CYP therapy service to provide SALT, occupational therapy (OT) and specialist physiotherapy, for CYP with either complex physical or speech and language and communication needs (SLCN), including the development of advanced clinical practice (ACP) roles to reduce pressure on community paediatrics and transition to adult pathways.

CYP voice and data intelligence

lived experience intelligence – understanding the lived experience of CYP with SEND and their families in relation to the services they access is already a well embedded approach with LCC’s commissioned suppliers. There is some evidence of CYP engagement and co-production within ICB commissioned providers, however, there is no central place across the system where this learning is shared. An aligned template for collection of feedback from CYP and their families is being developed
data intelligence – an integrated dashboard for SEND, including health related data, is being developed as a tool to bring statistics relating to EHC in one place. The dashboard will support work taking place across East Midlands in creating a regional dataset to support better understanding of local and regional SEND demand and need. Lincolnshire’s work will identify wider opportunities to improve the quality of intelligence through use of an ICS joined intelligence dataset which is in early stages of development.

Intelligence from both the lived experience and the dashboard will help identify where additional support may be required, or possibly reduced, to ensure our arrangements are making a positive difference for CYP with SEND. Having one joint approach will not only provide greater consistency for families, it will also help the ICB and LCC to identify trends and needs to shape and inform future integrated commissioning plans.

Integration of assessment processes and support for CYP with SEND review

Work of the review shall sit within three sub-categories:

SEND EHC process-strengthening accountability to drive better outcomes and experiences for CYP with SEND across the EHC process through high quality clinical and medical information and advice with clearly defined specific, measurable, achievable, realistic and timebound (SMART) health outcomes
independent placements for CYP with SEND- joint decision-making processes and funding arrangements shall be reviewed to ensure the right level of accountability is in place by all partners
children’s continuing care (CC) review for CYP with SEND - a review of Children’s CC service delivered by both LCC and the ICB. It can be evidenced through national and regional network meetings that CC is delivered differently within each ICB area; this has informed the need for this review

Health inequalities

Priorities continue to be driven by data and intelligence, including an evolving use of population health management information to ensure the work being undertaken addresses and understands health inequalities within our CYP population within Lincolnshire. The NHS England Core20PLUS5 programme outlines key priorities to reduce health inequalities for CYP. The 5 clinical priorities for CYP are, asthma, diabetes, epilepsy, oral health, and mental health. These groups include CYP with SEND. The CYP programme directly aligns to these priorities. New national deliverables are expected relating to the CYP Core20Plus5 programmes, which will support our CYP programme further, for example, improving transition pathways and co-production with CYP and their families in capturing the CYP voice. This work will help us understand if there are particular issues for CYP with SEND in accessing the care they require and addressing any identified gaps. All projects within the ICB work programme 2023-28 shall include a transition workstream.

LYV

LYV have an updated service delivery plan which includes future work around improving accessibility to public transport and an educational programme to address bullying - the outcome of which is intended for use by CYP and professionals.

Recommissioning of an early learning and portage support service

Lincolnshire schools forum have recently agreed to continue supporting the funding of a service for children in their early years with suspected or diagnosed SEND where there is a learning difficulty, developmental delay or physical difficulty impacting on the child’s educational development. The current portage service offer is predominantly a home visiting service delivered across Lincolnshire by eight special school providers. The re-commissioned service will include a single lead provider model, with capacity realigned to geographical areas of demand to ensure an equitable offer for all eligible families. There will be a single point of access for referrals and a strong emphasis on offering coordinated and inclusive evidence-based group and workshop support within children’s centres and community venues, prior to home-based support being provided where there is an identified need.

Family hubs programme speech and language support pilot

An evaluation of the family hubs start for life offer in Lincolnshire will commence April 2024. This will include evidence-based programmes funded through the family hubs programme from conception through to the age of five years (early years foundation stage). Family hubs stem from clear evidence that identifying risks early and preventing problems escalating, means better long-term outcomes for children and their families. As a system we will review the evidence-based outcomes from the family hubs programme in order to identify the areas that have had the most positive impact for young children and their families, with a key focus on the first 1,001 days in a child’s life, that with sustainable funding investment could continue to improve the outcomes and life chances for Lincolnshire children and their families.

Families first for children pathfinder

The pathfinder is part of the government’s children's social care: stable homes, built on love and is part of phase one of the government’s social care reform programme: laying foundations for whole system reform to design and test key social care reforms and policies in relation to family help and child protection. Lincolnshire has been pre-selected as one of three local authorities to take part in wave one of the pathfinder to implement and test delivery against minimum expectations with a view to influencing the national vision. LCC is working in partnership with ICB, health, education and police colleagues to build upon our existing strengths and identify areas of improvement and development that will help to further improve outcomes for Lincolnshire families and share learning with strategic and national partners.

CYP mental health transformation programme

Together with CYP in Lincolnshire, will transform services in Lincolnshire by 2028 to improve emotional wellbeing and mental health support for CYP and families, enabling them to live independent, safe, well and fulfilled lives in their local communities. We will focus on improving support for CYP and their families through:

increasing public mental health promotion, prevention, community and early intervention support
empowering parents, carers and professionals working with CYP to better identify and respond to emotional wellbeing and mental health concerns
increasing and improving access to community based emotional wellbeing and high-quality, evidence-based and timely mental health assessment and support
ensuring that CYP with a learning disability or autistic CYP who are also suffering from mental illnesses receive specialist care that is tailored and able to meet their specific needs
avoiding unnecessary specialist and acute mental health related hospital admissions, particularly for CYP with a learning disability or who are autistic

Autism diagnostic pathway

Despite investment in the autism diagnostic pathway in Lincolnshire and improved waiting times being achieved, post pandemic demand for assessment has increased significantly again. This is also the case nationally. A new and improved pathway has been designed that would allow appropriate clinicians in Lincolnshire to assess and diagnose autism in CYP up to the age of 18. This has been co-developed with the autistic community and specialist clinicians to make it a simpler journey for both CYP and families, as well as for professionals. During 2024 system leaders are working together to agree how to transform the existing autism diagnostic process and how to potentially fund and implement the newly co-produced pathway design. The new pathway would include more focus on offering support to the CYP and family throughout the assessment process, as well as post-diagnostic outcome. This would help us to achieve reduced waiting times, address increasing numbers of referrals for assessment and simplify the process for families.

Sensory processing difficulties (SPD)

SPD can cause issues at home, in education settings or in the community. Partners across the system state many CYP would not require OT intervention, or may need less specialist intervention, if they received focussed support earlier. Unmet needs are escalating and leading to more costly specialist services. Over 2024 the mental health learning disability and autism programme of work shall consider the need for a stepped model; initially requiring ownership by the parents, carer or CYP, moving on to later stages of more tailored, specialist-led support as required.

Neurodevelopmental pathway

Many of these conditions, including autism, are the most common lifelong conditions in our SEND population. However, there is currently no diagnostic pathway for CYP with suspected learning or intellectual disabilities in Lincolnshire, or for CYP with suspected tics or tourettes, and CYP aged 16-17 with suspected autism. Plans are being developed to address these gaps. Initially through strengthened out of area treatment panel integrated commissioning arrangements (as an interim) with longer-term plans to develop Lincolnshire’s existing commissioned services and pathways.

Admission avoidance

Plans are being discussed to develop joint mental health crisis provision in Lincolnshire, including for autistic CYP or those with LD. More resource has also been agreed for CYP mental health crisis liaison across Lincoln and Boston (outreaching to Skegness and Grantham), further supported by making the Lincoln hospital mental health urgent assessment centre (MHUAC) all-age from 4 December 2023. A review of the processes for inclusion or addition of CYP on the DSR, including across health, social care and education partners as well as potential self-referral, is being undertaken. This will also include processes for identifying those at risk on 38 or 52 week placements, as well as reviewing the progress with wider processes for multi-agency monitoring and support and care planning.

CYP keyworking

The keyworking offer is being further strengthened since going live with the full 0-25 offer, by recruiting additional fixed-term band 5 keyworkers. The service will focus on further building relationships with the VCSE sector in Lincolnshire; continue to work with those with lived experience, service users and external stakeholders to co-produce service improvements; and will further improve relationships with social care and education partners, with a continued focus on facilitating system partnership working. Since the service is still relatively new, there is also ongoing work to improve understanding of the CYP keyworker service across other services and professional groups, and to establish relationships with the new virtual autism hub.