Mr. Mark Smyth:

I thank the Chairperson and members of the joint committee, on behalf of the Psychological Society of Ireland, PSI, the Association of Occupational Therapists in Ireland, AOTI, and the Irish Association of Speech and Language Therapists, IASLT, for the opportunity to address them. We welcome the opportunity to contribute to the discussion generated by the report from the Ombudsman for Children titled Unmet Needs.

Our representative bodies share the concerns of the Ombudsman for Children about the unacceptable delays that have been experienced by many children and families who have required an assessment of their needs. There has been a long and sad legacy of assessments not being completed within specified statutory timeframes. This has resulted in parents and children enduring years on waiting lists, having to pay for expensive private assessments or trying to challenge the HSE in the courts to have their children’s needs identified. None of this is good enough.

To complete evidence-based assessments in a timely fashion, children’s disability services and assessments of need should have been resourced with the required staffing. Instead of providing the staffing required, the HSE has embarked on an alternative, less widely publicised pathway that is of great concern and which we draw to the attention of the committee. In January 2020, the HSE implemented a new standard operating procedure, SOP, for assessments of need across the country. While our professional bodies are supportive of an SOP in principle, we have significant concerns regarding the procedure in its current iteration. All of these concerns were relayed to the Oireachtas Joint Committee on Health in and were reflected in the final report by the on the matter. The implementation of the new SOP has proceeded despite our professional bodies clearly stating that it is not in the best interests of children and, we would contend, without in any way acknowledging the recommendations of the committee. Furthermore, the commitment to meaningful engagement with professional bodies to address our concerns given by the HSE to the health committee in 2018 was not honoured.

It remains our considered opinion that the changes to clinical practice described within the SOP will, in many cases, prove detrimental to children and their families. Our members are also concerned that compliance with the SOP could lead to them being in breach of codes of conduct and ethics of their respective professional body and the Health and Social Care Professionals Council, CORU. The SOP is neither evidence based nor based on good practice in assessment of children with disabilities.

It is our opinion that the preliminary team assessment, PTA, model embedded within the SOP being implemented by the HSE is contrary to the spirit of the Disability Act 2005, which was developed as rights-based legislation. The PTA is a brief screening assessment. Its introduction has significantly reduced the level of assessment provided to a child under the statutory framework of assessment of need. Prior to the SOP, the child’s needs determined the level and type of assessment provided. These assessments varied substantially because children’s needs vary. However, the SOP replaces this with a uniform screening assessment to be completed by two clinicians in a maximum of 90 minutes, regardless of the child’s presentation and needs.

The new SOP does not facilitate the diagnosis of, for example, autism spectrum disorder or intellectual disability and will no longer be provided as a part of the assessment of need protocol. Instead, children will be identified as having "health needs" in the service statement.

The Disability Act states that an assessment report will state whether the applicant has a disability, indicate the nature and extent of any disability and describe both the health and education needs occasioned by the disability, as well as the health or education services required to meet those needs. It is our view that in the majority of cases it will not be possible for a psychologist, an occupational therapist or a speech and language therapist to answer these questions or to feed these back to parents within the maximum timeframe permitted within the SOP of 90 minutes. Adequate time with parents or guardians and the child is required for the purposes of direct assessment. It is also essential to give parents or guardians time at the conclusion of an assessment to process their reactions to any diagnosis or other feedback.

In our opinion the HSE’s introduction of the PTA in place of comprehensive assessments will give rise to the following risks. A child may be deemed likely to have a disability but require further comprehensive assessment to determine the nature and extent of their disability. However, as the child will already have completed his or her assessment of need, AON, as defined in the SOP and not the Disability Act, there will be no defined legal timeframe within which this further assessment must be carried out. Our members have reported that since the implementation of the PTA this month, the outcome in almost all cases has been a recommendation for further assessment. It is crucial to note that this further assessment will not occur within the legislative framework of the Disability Act. Accordingly, there are no statutory requirements for assessments to be completed within an acceptable timeframe. It is also important to consider that this is only to complete an assessment to identify needs. This is not the same as receiving intervention which should follow assessment.

A child may incorrectly be deemed not to have a disability because the disability was not apparent during the brief 90-minute screening. The absence of evidence in a single screening session and setting is insufficient evidence to warrant a determination of the absence of a disability. If a child receives an incorrect determination of no disability, he or she will consequently be denied more comprehensive assessment and receive either no or inappropriate intervention. A child’s difficulties may be incorrectly outlined due to a comprehensive assessment not being permitted within the PTA model.

In many geographical areas, each of these scenarios will result in substantial delays for many children and their families in accessing a wide range of appropriate and needs-based financial supports, educational provision and health services. In addition, in many cases children risk being placed on potentially inappropriate and long waiting lists for assessment or intervention.

The Disability Act does not entitle children with disabilities to services to meet needs identified through the AON process. Having often waited for lengthy periods for full assessment to be completed, children with identified needs then must go on a new waiting list to receive psychology, occupational therapy and speech and language therapy services. The wait time for these services can be months to years depending on geographical location.

Rather than seek to address those challenges identified by the Ombudsman for Children, the primary goal of the new SOP would appear to be solely to enable the HSE to meet its statutory obligations under the Disability Act. In order to achieve this goal, the SOP seeks to replace a comprehensive professional assessment process with a uniform brief screening session, as well as to designate diagnostic assessments as health needs. We are already seeing the entirely predictable result where the assessment of a child’s needs indicates that the child needs an assessment. The original mistake made in developing the AON process was in separating assessment from intervention. Assessment and intervention should be part of a seamless service offered to children with difficulties. This flaw in the system is now further compounded by the PTA.

Four case vignettes attached to our written submission briefly illustrate what is now happening every day across the country. The implementation of this new approach will exacerbate an already intolerable situation for children and their families. The Psychological Society of Ireland, the Association of Occupational Therapists of Ireland and the Irish Association of Speech and Language Therapists seek the support of the committee in recommending an immediate cessation of the SOP. We also seek the committee’s support in recommending the HSE take a standards-based approach grounded in good practice models of professional assessment of children with disabilities.