Disabled children and young people up to 25 with severe complex needs: integrated service delivery and organisation across health, social care and education

Why the committee made the recommendations

There was moderate-quality qualitative evidence on the experience of practitioners from different services working together:

To address this evidence, the committee made a recommendation on collaborating to develop a positive working culture.

Moderate-quality qualitative evidence also showed that using a consistent approach when interacting with children and young people was beneficial. It made services more predictable for children and young people, and made things easier for them to understand when dealing with a new service. The recommendation on arranging handovers will help to improve consistency and reduce the need for children, young people and their families and carers to repeat information.

There was limited quantitative evidence that having a local assessment team reduced waiting times for assessment. However, there was only 1 study in this area, focusing on children and young people with autism. It was very low quality, and reported on waiting times only. Because of these problems with the evidence, local assessment teams were not recommended.

The committee did agree that practitioners would be better able to coordinate with each other and provide information to children and young people if they understood the responsibilities of other practitioners and services involved in supporting the education, health and care needs of the child or young person. The need for more coordinated support was highlighted by moderate-quality qualitative evidence that service providers value the different skill sets and knowledge of others and opportunities to learn from each other and build expertise. In the committee's experience, service providers already gain an understanding of the responsibilities of other people and services in an ad hoc way; the recommendations would simply encourage a proactive approach.

How the recommendations might affect services

The recommendations reinforce principles of good practice and should not represent a change for most services. However, some underperforming services may have to implement more effective practices, for example around arranging handovers.

Services will also have to develop interagency training for practitioners on other services and their roles and responsibilities. Extra practitioner time might be needed to provide more wide-ranging and coordinated support. However, if practitioners are better trained on the roles and responsibilities of other services, this may lead to more efficient and timely delivery of care, with less duplication.

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Why the committee made the recommendation

There was moderate-quality qualitative evidence that joint working improved when practitioners had shared values and priorities. From their experience, the committee agreed there is difficulty in practitioners from different services building effective teams and relationships with each other without having dedicated time for this and support from managers.

How the recommendation might affect services

Services will need to give practitioners dedicated time for team and relationship building.

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Why the committee made the recommendations

There was no evidence comparing services that did and did not have key workers, so the committee made a research recommendation about the effectiveness of dedicated key workers. However, moderate-quality qualitative evidence showed that key workers are seen as important by families and practitioners, for being able to better understand the child or young person's needs, and for being able to coordinate services. Moderate-quality qualitative evidence also highlighted that having a single person for families to contact would simplify processes and be beneficial to joint working. The committee's understanding of the special educational needs and disability (SEND) code of practice is that it recommends that local authorities should adopt a key working approach, to provide a single point of regular and consistent contact, and help ensure holistic provision and coordination of services and support. However, in the committee's experience this is not happening consistently and there is variation in understanding of what key working may involve. The committee were confident that providing effective key working support to everyone who needs it requires flexibility in the support that is provided, tailoring of the support to individual needs and consideration of family circumstances.

Very-low-quality qualitative evidence highlighted that families are less accepting of key workers who have not had much involvement with the family. To address this, the committee made a recommendation on how to choose a key worker who could actively engage and work well with the family.

Low- and moderate-quality qualitative evidence also showed that:

The committee made a recommendation on the responsibilities of the practitioner providing key working support, to address the problems identified in the evidence. These responsibilities align with the committee's understanding of the key working functions set out in the SEND code of practice.

Based on their experience, the committee were confident that key working support can only be effective if senior managers support practitioners, ensuring they have the training, time and resources needed and understand what key working support involves. Without involvement from senior managers, there is inconsistent provision. Some children and young people miss out on key working support, and others do not receive good-quality support.

In the committee's experience, information sharing and governance arrangements are needed to ensure that key working support functions can be delivered across different services.

Moderate-quality qualitative evidence showed that the continuity of key workers is important for consistency (particularly during transition to adult services), and that children and young people felt negatively when key worker support ended prematurely. Staff turnover is inevitable, so it is important that good handover and contingency plans are in place to maintain consistency and minimise the impact of changes on children and young people.

In the committee's experience, some families do not have a permanently fixed location and move frequently. This can cause difficulties with effective coordination of care and support and timely transfer of information. The committee made recommendations on the actions needed when families move to a new area, to prevent inequalities in access.

How the recommendations might affect services

The committee's understanding of the SEND code of practice is that it recommends a key working approach (paragraph 2.21). However, this has never been fully implemented, and practitioners providing key working support do not have enough allocated time to provide all these functions. Because the recommendations on key working support are in line with the committee's understanding of the SEND code of practice, there should not be a significant resource impact. However, practice is variable, and the implementation of these recommendations might require additional resources for services with suboptimal practices. Services will need to make changes to enable key working approaches. They will also need to ensure caseloads are manageable and practitioners have dedicated resources to deliver effective key working.

A dedicated key worker role would be preferred, with a separate job description and role specification, rather than key working functions being allocated to members of the team on top of their existing roles. However, there was no evidence of effectiveness or cost effectiveness to justify a specific key worker post.

Using a key working approach will ensure a single point of regular and consistent contact to help ensure holistic provision and coordination of services and support. It will reduce the burden on families to coordinate care, meaning they no longer have to spend as much time away from their other commitments, including care for siblings and time off work, which should increase their ability to manage at home, avoiding the cost of expensive care placements. Because of the current lack of key working support, there are routine reports of communication and coordination failures (that is, different services not working well with each other), leading to inefficient processes, missed meetings and poor information provision. Using a key working approach will counteract this and ensure coordinated and seamless care, joined-up outcomes, and a reduction in complaints.

There is no bespoke training for practitioners who will be providing key working support. The essential skills needed involve project management, negotiation, and communication, and usually involve component-based training.

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Why the committee made the recommendation

Moderate-quality qualitative evidence highlighted that there is a lack of transparency about how decisions are made on education, health and care (EHC) plans, the timescales for reviews, and the processes for appeals or complaints. Although the evidence was only about the EHC plan process, the committee agreed, based on their experience, that having increased transparency about what services do and how they work together would improve the child or young person's understanding of how to navigate the system. It would also increase their confidence in the care and support they are receiving and empower them to be more assertive about their needs. So the committee agreed services should consider doing this.

How the recommendation might affect services

Making processes more consistent and transparent may mean more practitioner time is needed, to improve coordination and joined-up working, and for learning about the roles and responsibilities of other practitioners.

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Why the committee made the recommendations

The committee used themes from the qualitative evidence to make recommendations on training for education, health and social care services.

Moderate-quality evidence showed that joint working was negatively affected when practitioners did not understand the roles, responsibilities and expectations of other practitioners or services. Based on their experience, the committee agreed that training could help.

Moderate-quality evidence showed that education providers need support and training to help them integrate disabled children and young people with severe complex needs into mainstream education.

High-quality evidence showed that practitioners do not always understand the social, emotional and mental health needs of disabled children and young people with severe complex needs. When these needs are not recognised and addressed, it can be more difficult for children and young people to get EHC plans. The committee agreed that training was needed to help practitioners recognise these needs.

Moderate-quality qualitative evidence showed that:

The committee were confident that children, young people and parents and carers need to be involved in developing awareness training programmes that are for them or that help practitioners work more effectively with them, to ensure that training is targeted and relevant. This was supported by moderate-quality qualitative evidence that parents and carers felt positive when given the opportunity to provide their views, and praised practitioners who valued their expertise but maintained appropriate boundaries. In the committee's experience, the development of training programmes did not always involve children, young people or parents and carers.

There was very-low-quality quantitative evidence that practitioners were better able to meet the needs of disabled children and young people after gaining experience working in other settings. Although this experience was referred to as a secondment in the evidence, the committee agreed that the intervention more closely resembled short-term observational placements, and made recommendations in support of these. This was supported by moderate-quality qualitative evidence that service providers value the different skill sets and knowledge of practitioners from other sectors and opportunities to learn from each other and build expertise. Regular contact among professionals was valued as a way to improve relationships and effective team working. Low-quality evidence also suggested that sharing staff across multiple settings improved knowledge of the child or young person.

How the recommendations might affect services

Currently, while training is provided within each sector about support needs presenting across settings (for example, safe eating and drinking, and personal care), this training is not run jointly. Doing so would be a change in practice. Services will have to develop interagency training for practitioners, but this will reduce conflicting advice, encourage all 3 sectors to work together more efficiently, cut out duplication, and potentially reduce training costs to individual services. Funds to provide the training already exist. Services will only need to reprioritise and reorganise their existing training budgets to deliver this. Joint training will enable practitioners to get insight into other professional perspectives, which should ultimately improve the support provided to disabled children and young people with severe complex needs.

Other recommended training already exists (for example, training on the EHC needs assessment process, and recognising social, emotional and mental health needs). However, it is not available everywhere, and the recommendations may represent a change in practice for some services. This training could be provided in various low-cost ways, for example remotely, as pre-recorded sessions. The benefits of these training programmes could be substantial. For example, training to recognise social, emotional and mental health needs should result in those needs being identified sooner, so that earlier, less intensive interventions can be provided. It should also help prevent children and young people from reaching a crisis point that significantly affects their quality of life and is more costly to address.

Providing short-term placements so practitioners can gain experience in a different sector is not widespread current practice. However, it is unlikely to have significant resource implications because employers already have funds set aside for training their workforce, and some of these funds could be used to fund the placements.

Children, young people and parents and carers are not always involved in the development of awareness training programmes, so this recommendation may represent a change in practice for some services. There may be some additional resources required, such as extra practitioner time, to help them get involved.

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Why the committee made the recommendations

There was moderate-quality qualitative evidence from both families and service providers that professionals and staff lacked the necessary skills and knowledge to meet the needs of disabled children and young people with severe complex needs.

In moderate-quality qualitative evidence, families who were delivering interventions reported anxiety about not having enough time to discuss these interventions with professionals and staff and make sure they were doing them properly. The committee directed people to guidance from the relevant professional governance organisations because they provide advice on training and competency in delegated clinical tasks. Separate guidance was made for support workers and parents and family members, to reflect variances in the training, competency and support needs of these groups.

The committee were confident it was important that children, young people and their families and carers are asked for feedback because they may have different perspectives from practitioners and it is important to get this input to ensure they are getting effective care and support. Processes should be in place for addressing this feedback, so that improvements can be made.

How the recommendations might affect services

The recommendations in this area make other guidance more explicit. There are wide variations in practice across the country about how this guidance is understood and implemented, including some poor practice. The recommendations should make practice less variable. They may also prevent a breakdown in interagency working and prevent critical incidents that could have a detrimental effect on children and young people and substantial financial implications for services.

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Why the committee made the recommendations

There was very-low-quality quantitative evidence that when practitioners work together as part of an interagency team, rather than working individually, children and young people benefit through increased participation, inclusion and educational achievement. Despite the low quality of the evidence, the committee were confident that working together in a coordinated way across education, health and social care services would improve care and support for children and young people. It is also important to ensure that interagency teams have the right practitioners, with the skills and experience to meet all of the child or young person's needs. Moderate-quality qualitative evidence reflected that a lack of skills, knowledge and training among practitioners was preventing them from working effectively to meet the needs of children and young people.

In the committee's experience, working relationships between practitioners improve when there is an opportunity to air and resolve disputes. The committee agreed that most services have existing procedures and policies to do this internally, but procedures for resolving interagency disagreements were needed to facilitate the joint integrated working emphasised by this guideline and the legislation.

There was evidence of an important benefit of a collaborative life skills programme involving an active partnership of parents, teachers and school clinicians in increasing the participation and inclusion, and educational achievement or attainment in disabled children and young people with severe complex needs. This evidence was very low quality so the committee did not recommend this specific intervention. However, they agreed on the importance of collaborative working across education, health and social care services to ensure that the child or young person's needs are accounted for in all settings.

Moderate- and high-quality qualitative evidence highlighted practitioners need more training to meet the needs of disabled children and young people with severe complex needs. However, there was limited evidence about what the content of this training should be. In the committee's experience, learning from other practitioners in the interagency team can be a useful way of finding out about the child or young person's needs and possible approaches for meeting those needs. This was consistent with low-quality qualitative evidence that sharing information increases understanding of the child or young person and their needs. There was also moderate-quality qualitative evidence that practitioners value the skills and knowledge of others, and want opportunities to learn from each other and build expertise.

There was limited evidence, based on the experiences of a traumatic brain injury consulting team, that workshops, inter-professional education and ongoing supervision improved the team's ability to meet the needs of children and young people. However, this approach was not recommended because the evidence was limited in terms of both quality and the population it covered, and it did not report how effective the consulting team were at supporting other practitioners.

In the committee's experience, individual members of the interagency team often have a wealth of specialist knowledge and information that can be used to improve the care and support provided to disabled children and young people with severe complex needs. The committee felt strongly that this knowledge and information should be shared between members of the interagency team and were confident that doing so would mean they can provide more comprehensive care and support and meet the child or young person's needs more effectively. Based on their experience, they suggested areas of specialist knowledge that could be shared.

Moderate-quality qualitative evidence showed that there can be negative relationships between professionals, leading to disagreements. In the committee's experience, interagency teams need the opportunity to air and resolve disputes to improve working relationships guided by policies and procedures that have been created for resolving interagency disagreements.

How the recommendations might affect services

There will already be a team of education, health and social care practitioners who are working together with the family to support the child or young person. The recommendation on interagency teams is about formally organising this, so it reinforces current practice. It may mean that interagency teams include a more comprehensive range of practitioners, with the skills and experience to address all the needs of the child or young person.

The recommendations imply greater sharing of knowledge within existing interagency team meetings. Teams that do not do this will have to set dedicated time at team meetings to discuss changes in practice, legislation or statutory guidance. Interagency teams already have ways of resolving disagreements between different practitioners. Some resources might be needed to agree and formalise these practices.

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Why the committee made the recommendations

The committee agreed that early intervention and multi-agency involvement will help to identify, assess and address the needs of disabled children and young people with severe complex needs and prevent them reaching crisis point. This was supported by moderate-quality qualitative evidence reporting that services can be slow to provide support until children and young people reach crisis points.

Some disabled children and young people with severe complex needs are cared for in specialist residential placements that may be some distance from their home. The committee agreed that, for some children and young people, this may be the most effective option, because it is difficult to meet their support needs any other way. However, in the committee's experience, long-distance placements are also made for some children and young people because there are no local services available to provide the care they need, or because they do not meet the eligibility criteria for local services. The committee were confident that providing care within their community would be beneficial for children, young people and their families and carers, improving their quality of life and maintaining their family and social relationships. The committee therefore agreed, based on their experience, to recommend exploring all local options before using long-distance placements. They also made a research recommendation to establish the most effective commissioning, practice and service delivery models for enabling children and young people to stay close to home.

In the committee's experience, it is widespread practice for services to be commissioned and developed based on replicating existing services rather than based on services that meet the needs of the population. This approach does not necessarily consider what the outcomes of such services should be. Specifying outcomes in contracts would lead to services that are better equipped to meet the needs of disabled children and young people with severe complex needs.

In the committee's experience, services often work in isolation and do not consider the effect that changes in service structure or processes may have on other services involved in the care of disabled children and young people. This can cause delays and gaps in service provision.

There was moderate-quality qualitative evidence that the services provided often do not meet the needs of children and young people, because of a lack of funding and resources. This is a particular problem for young people over 16. There was also moderate-quality qualitative evidence that decisions on transition are left too late, further affecting young people. In the committee's experience, working together to plan how services will be funded and organised once young people turn 18 or transfer into adult services would ensure continuity of support and lead to more effective use of limited resources.

There may be health reasons to limit some specialised services based on diagnosis. However, in general the committee felt strongly that, in line with their understanding of the SEND code of practice, support should be provided based on needs rather than diagnosis. This was supported by moderate-quality qualitative evidence from both families and practitioners suggesting that this would minimise gaps in service provision.

In the committee's experience, services sometimes deprioritise children and young people on their waiting lists to meet organisational and statutory targets. If the statutory deadline for producing the EHC plan has been missed for a child, they may then be forced to wait even longer, as services prioritise meeting the deadline for other children or young people. Although this allows organisations to meet more statutory deadlines overall, in practice it penalises some children and young people for no practical reason and may exacerbate their needs. The committee were confident that a recommendation was needed to discourage this.

There was low-quality qualitative evidence of a lack of clear pathways for referral between services. This aligned with the experience of the committee, who felt strongly that the processes for referral needed to be more effective. They were confident that doing this will help practitioners provide effective and coordinated care and support to disabled children and young people with severe complex needs. They made recommendations on how to do this.

There was some evidence involving parents in steering committees and advisory groups could improve their quality of life. There was also moderate-quality qualitative evidence that using a more flexible approach would be beneficial. A flexible approach is when services work to meet the individual needs of the child or young person, rather than fitting the child or young person within existing rigid service models.

Moderate-quality qualitative evidence reported families feeling disillusioned with statutory provisions and seeing little point in requesting help, leading to occasions when they opted out of seeking support. The committee agreed that getting the views of service users on the effectiveness of services could potentially improve statutory provisions and subsequently reduce the disillusionment about current services. This is in line with the committee's understanding of the SEND code of practice, which specifies that children and young people with special educational needs and disabilities and their parents must be engaged in commissioning decisions, so that users' experiences, ambitions and expectations can shape decisions on the services provided. The committee's understanding of the SEND code of practice was also that children and young people with special educational needs and disabilities and their parents must be consulted when reviewing educational and training provision and social care provision.

The committee's understanding of the SEND code of practice is that services should be commissioned based on the needs of people in that area. However, in their experience the committee has seen the opposite happening, with people being expected to just use services that already exist. The committee made a recommendation to discourage this.

There was some evidence that dedicated funding for services, joint budgets and having a designated service manager improved parents' satisfaction and quality of life. However, this evidence was very limited and was specifically related to the provision of key workers. There was also insufficient information in the studies on the exact funding and commissioning arrangements. Therefore, the committee recommended further research into the most effective joint commissioning arrangements for disabled children and young people with severe complex needs.

How the recommendations might affect services

The recommendations reinforce existing legislation and statutory guidance and would only represent a change in practice for services that are not compliant with these.

Coordinated and joint-working practices are not consistent. Commissioners will have to set up or use existing commissioning frameworks to reinforce joint working and to ensure that children, young people, parents and carers are involved in planning services. In practice, this will mean more practitioner time, more meetings and more communication between education, health and social care services.

Education, health, and social care services working together in an integrated way will deliver better, more joined-up, holistic services to children and young people with disabilities and severe complex needs to keep them supported within their families and local communities. This will lead to early identification of needs (before they reach a crisis), and reduce the need for expensive, often extended, hospital stays. This may also prevent expensive out-of-area placements. Ultimately, integrated ways of working achieve better outcomes for children and young people with severe complex needs, for example maintaining independence, improving health outcomes and quality of life, and general wellbeing. This would also improve educational outcomes by getting the right support for engaging in learning earlier.

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Why the committee made the recommendations

There was high-quality qualitative evidence that the paperwork and processes of EHC plans are revised without service providers being given any notice or consultation. The committee agreed that this is a source of inefficiency and frustration, and made recommendations to involve services and commissioners more closely in the process.

There was moderate-quality qualitative evidence that both service providers and families have trouble understanding the EHC plan process. Services are concerned about their lack of training and knowledge on how to support the development of EHC plans, which potentially leads to discrepancies and a lack of consistency. Local authorities are responsible for the EHC process, so the committee recommended that they provide training on this for practitioners. Producing good-quality EHC plans is crucial to ensuring that disabled children and young people with severe complex needs get the support that they need.

In the committee's experience, short breaks help parents and carers with the delivery of care by providing respite. This was supported by moderate-quality qualitative evidence. Although the Breaks for Carers of Disabled Children Regulations 2011 requires local authorities to provide short break services, in the committee's experience the range of options can be constrained by the resources currently available in their area. The committee were confident that the most successful and valuable short breaks are those provided in consultation with parents or carers, and tailored to their specific needs. Therefore, they highlighted the requirement in the regulations that a range of short breaks must be provided.

There is no evidence on the effectiveness of short breaks. So it is not clear which aspects of short breaks are most effective or why children and young people and their families and carers prefer some short breaks over others. The committee agreed that a research recommendation was needed to determine which components of short break services are most effective.

How the recommendations might affect services

Local authorities will have to spend more time explaining EHC plan process changes to education, health and social care services. If practitioners understand the process better, this will lead to production of better EHC plans, and ultimately more efficient delivery of services, increased transparency, and more timely care.

Training on the EHC needs assessment process already exists within most services. This training could be provided in various low-cost ways, for example remotely, as pre-recorded sessions. Such training will reduce conflicting advice and encourage all 3 sectors to work together more efficiently, minimising duplication.

Recommendations on short breaks reiterate the duty under the Breaks for Carers of Disabled Children Regulations 2011.

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Why the committee made the recommendations

In the committee's experience, not everyone knows that the SEND Local Offer provides information about the services and support that are available for disabled children and young people and their families. To prevent inequality in access, they made recommendations about what should be included in the SEND Local Offer.

The SEND Regulations 2014 specify what information must be included in the SEND Local Offer. A variety of themes from the qualitative evidence highlighted areas where information provision was poor or lacking. The committee used these themes to make recommendations highlighting what local authorities should include in their SEND Local Offer, that were consistent with the regulations and guidance in the SEND code of practice.

The committee mentioned eligibility criteria used in the EHC needs assessment process in response to low-quality qualitative evidence. This showed that families thought their child had to reach a crisis point before an EHC plan was considered necessary.

In response to low-quality qualitative evidence that practitioners felt pressure not to apply for an EHC plan because of funding issues, the committee recommended explaining the criteria for an EHC needs assessment.

There was qualitative evidence that children and young people and their families and carers need more information to understand and access available services. Assistive technology is highlighted because there were specific concerns in the qualitative evidence about the lack of training and knowledge of staff in this area.

The committee agreed, based on their experience, that details of social activities should be included. This is because social inclusion is as important as care and education for improving the quality of life of disabled children and young people.

Providing details of support to assist with preparation for adulthood and independent living in the SEND Local Offer is a requirement of the SEND Regulations 2014. The SEND code of practice provides guidance on what information about employment should be provided. In the committee's experience, employment may be a daunting prospect for disabled children and young people, but this can be improved when local authorities make the available services clear.

In line with the Children and Families Act 2014 and SEND Regulations 2014, local authorities must involve children, young people and their parents in planning and reviewing the content of the SEND Local Offer, which gives families the opportunity to say what services they think are needed and raise issues if they are not happy with what is available.

How the recommendations might affect services

The information local authorities include in their SEND Local Offers varies, and the recommendations will help reduce this variation. Local authorities that do not currently provide this information may need to spend more time and resources collecting it and including it in the SEND Local Offer.

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Why the committee made the recommendations

There is a joint commissioning duty in the Children and Families Act 2014, between clinical commissioning groups and local authorities. However, this is only happening in parts of the system. There is no universally established framework at an organisational level to enable joint working across all 3 sectors. Many of the recommendations in this guideline emphasise the need for joint working, but the ability of services to implement these would be limited without a framework being established at an organisational level. The committee noted that the commissioning duty of clinical commissioning groups is being absorbed by integrated care systems and therefore the same duty should apply to the relationship between integrated care systems and local authorities, so they recommended developing a joint commissioning framework.

In the committee's view, interagency team working will only be effective if there is a formal commitment, setting out how providers and services should work together in an integrated way. The committee were confident that effective interagency team working is of central importance to improving support for disabled children and young people with severe complex needs, and so made recommendations on how to achieve this. Based on their experience, they agreed that the mechanisms to achieve effective integrated working would be for commissioners to specify how services should work together in contract requirements; for senior managers in all services to have processes in place to support interagency team working; and for providers to have agreements setting out how they will work together.

Clinical commissioning groups are required to develop and maintain dynamic support registers. However, education and social care services are often not aware of these registers. Dynamic support registers are a useful source of information on children and young people who are likely to need additional support. In turn, this should make it easier to recognise early signs that might lead to a crisis, and enable extra support to prevent unnecessary hospitalisation.

How the recommendations might affect services

Integrated care systems are replacing clinical commissioning groups and may need to work collaboratively with local authorities where they are not already doing so, which potentially could have some resource implications. Joint commissioning of services is currently only being done for particular provisions, for example some patient advice and support services, some bespoke packages for post‑16s, and some short breaks. Developing a joint commissioning framework would be a change in practice. Given the integral part local authorities play in the identification, assessment and care pathways for children and young people with disabilities and severe complex needs, joint working (facilitated by a joint commissioning framework) is essential to bring meaningful improvements in the care of these children and young people.

A joint commissioning framework across education, health and social care will enable collaborative working, coordination, consistency and efficiencies for all parties involved. It will enable holistic care and a less fragmented experience. It will also allow practitioners to deliver person-centred care that addresses their needs across the 3 sectors, and ultimately, it will result in better care and support for the person. For example, better joined-up working will lead to early identification of needs (before they reach a crisis). This may prevent expensive out-of-area placements and prolonged hospital stays. It will improve health outcomes because the right care can be started early, avoiding the delays in care that exacerbate problems. This would also improve educational outcomes by getting the right support for engaging in learning earlier.

Education, health and social care services will have to make their processes more joined-up and coordinated. They may need more joint and collaborative meetings. Commissioners will need to establish frameworks for collaborative and cooperative working.

Dynamic support registers are an existing requirement, so there should not be a significant resource implication from this recommendation. There may need to be a change in practice in areas where these are not being used.

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