Room 3 - Delivery Room (Section 2 of 12)
Section 2 – Referral
Why referral is important
Referral is essentially the route by which children access the ‘system’, and gain entry into the provision of mobility and independence education in their school or home area. It should also be considered to be the ‘safety net’, ensuring that any child with a visual impairment in need of mobility and independence support is identified and provided for.
Activity 2
Think about the different types of referral which could be used. Before reading further about referral, consider first why it might not be sensible to wait until the child experiences difficulties before he or she is referred to a specialist in the field of M&I education.
The ‘problem’ with leaving the referral until there is an apparent problem may be two-fold. Firstly, the child may have developed bad habits that are difficult to correct, or may have lost their confidence. Secondly, this means you may be leaving the timing of a referral to someone who does not have very much experience of children with visual impairment. For example, it is possible that someone who knows little about children with visual impairment may assume that a child’s apparent clumsiness is simply ‘what children with visual impairment do’ and that intervention could not help.
Therefore we put forward a recommendation that all children with a visual impairment should have a basic assessment to determine whether they require mobility and independence support immediately or potentially in the future.
General principle: criteria for access to M&I education
Key recommendation 5 from research
All children with a visual impairment should have a basic assessment to determine whether they require mobility and independence support immediately or potentially in the future.
The key principle captured in this key recommendation taken from the full research report is that all students with a visual impairment may require additional educational interventions in the area of M&I at some point (especially given the broad definition of M&I we have adopted). Our research identified other principles that were adopted by different providers for accessing M&I support, including:
- The registration of a child as blind or partially sighted
- The identification of mobility and independence needs on a statement of SEN
While both these are useful indications of at least an assessment for M&I being required, it was noted that both might have shortfalls which may result in some children being overlooked. The use of a statement or local authority registration as a criterion is not sensitive enough, as children without either may require mobility and independence support. For example, there were examples within the study (and elsewhere) of a reluctance to register children as blind or partially sighted for various reasons, e.g. a changing condition, or parents may simply prefer not to.
When to refer and who should be involved
Activity 3
Prior to reading further, note down at least two criteria that are used to ‘trigger’ referrals for children in either your own service or a service known to you. Once you have done this you can compare your notes with our findings from the M&I research project.
The findings of our research suggested that the criteria for when to refer children vary widely between services. There appear to be two different triggers for referral (as well as combinations):
- Automatically at ‘key points’ in children’s development
- In response to identified problems
- Automatically at ‘key points’ in development
Referral takes place at key points in a child’s childhood/school career. Crucial times identified are:
- Pre-school
- At each key stage, ie. age 7, 11, 14
- Transition between schools/from the education system into adulthood.
Two examples of procedures identified in the research that aid this process are presented below. It should be noted that some children (e.g. those who are totally blind) may need continuous support throughout their school career and therefore ‘re-referral’ would not need to take place.
The M&I service uses a ‘transfer file’ that is constructed every year that lists children transferring to new schools who may require assessment. BIRMINGHAM
All QTVIs have additional mobility qualifications and carry out assessments with all children on their caseload at some point in each key stage.
Referral of pre-school pupils with visual impairment has particular challenges because there is such a range of provision. Sometimes an education service will have a pre-school service, sometimes not. Some education services have QTVIs with a pre-school caseload who provide mobility and independence support to the child and family where necessary, or liaise with other professionals involved (e.g. physiotherapist, occupational therapist). The general issue of pre-school provision is dealt with elsewhere. Nevertheless, examples of good practice in the referral of pre-school children from the research include:
Referrals from the health visitor are co-ordinated through the SENCO – children are referred at 3 or 4 years old to the MO who keeps in touch with the family, regardless of whether they have present mobility and independence needs, in case of later needs. RHONDDA-CYNON-TAFF
If the pre-school child is totally blind, the MO receives referrals from either the QTVI, community paediatrician, or social worker, but picks up children who are partially sighted when they start nursery. CARDIFF
Referrals for pre-schoolers are received from ophthalmologists at the children’s hospital or from health visitors, with whom she meets regularly. DERBY CITY
The education service has a huge pre-school caseload, referred by hospital doctors or the child development unit, or occasionally by the SENCO. COVENTRY
Post-school provision for young people who are visually impaired also has particular challenges. Many education services provide mobility and independence support to children aged from birth up to 19 years of age, but only if the child remains in LEA maintained education. Once they leave school to go to an FE college or to look for work, they are no longer supported (through the education service). Again, the quality of the service for these students very much relies upon the collaboration between different agencies (very often Education and Social Services). The general issue of post school provision is dealt with elsewhere.
In response to identified problems
Many services accept referrals from various people when they identify mobility and independence difficulties experienced by children who are visually impaired under their care, i.e. a reactive response.
The people involved in making referrals of this kind are:
- QTVIs – the most common referral route/person.
- Class teachers.
- SENCOs.
- Health visitor/other health professional.
- Parents/family
The problem with some of these routes is that other agencies, such as the health service, are often not aware of the availability of mobility and independence support.
The following are examples from our research of attempts to improve awareness:
The mobility and independence educator (MIE) should be responsible for raising awareness of the MIE role within the health field. There is a need for consistency in the information given. To enable this, the group is devising a booklet aimed at health workers to define the role of the MIE. MIDLAND MISE GROUP
A voluntary organisation that provides mobility and independence education (amongst other services) to people with visual impairment, distributes leaflets to all hospitals in the area to increase awareness about their service. BUCKINGHAMSHIRE
A further problem is that there is often a lack of clarity over who has responsibility or the right to make a referral. Even if responsibility/right is acknowledged, those involved often do not have the expertise to identify apparent problems, or the breadth of contact with a child. For example, a class teacher will not see the child beyond the classroom, and a parent may not have enough understanding about mobility and independence or what their child may be able to achieve. Therefore children may not be referred. The role of the QTVI is important here, as is the role of awareness training of others (parents, class teachers, SENCOs, health visitors) to enable those working most closely with children to be able to identify need.
Methods of referral – procedures
Activity 4
The M&I research project highlighted that the referral process should be as transparent as possible so that all involved can understand and follow the procedures. To ensure this, many services have a referral form to be completed by the person who is making a referral. Note down at least three reasons why you feel it is important to have an appropriate referral form. You can then compare your thoughts with the findings from the research project.
As previously discussed, those involved in making referrals may not have enough knowledge about mobility and independence, so may refer inappropriate or unnecessary cases, or fail to give all of the necessary information to the mobility and independence educator. A referral form ensures that this does not happen as it helps the referrer to clearly identify the problem, which in turn primes the mobility and independence educator on how to carry out the assessment – i.e. the context of what, where and when. Therefore it can be regarded as a preliminary assessment of the child.
A useful summary of the information a referral form should gather is:
- Details of the child and the visual impairment, and any additional disabilities.
- Reasons for referral.
- The referral form can be accompanied by a screening checklist – this is a first initial assessment of the child, the problems encountered, and the context, and helps prime the mobility and independence educator on how to carry out the assessment (e.g. BIRMINGHAM, DERBYSHIRE, MISE).
- There may be different checklists for different age groups (key stages), and wheelchair users (HULL).
The following are examples of how the referral form aids the referral process:
The referral form checklist is closely related to referral criteria. It is used as a ‘spot-check’ once per year by the QTVI to highlight any areas that require mobility and independence support. COVENTRY
The service has different screening checklists for Key Stages 1, 2, 3, 4 + wheelchair users. The MO then decides from the information given whether the case warrants an assessment. HULL
Parental consent
Many services operate a parental consent policy.
Activity 5
Parental consent for any input for M&I education is clearly an important issue to consider for all professionals working with children. Before reading on, note down at least three key elements that should be considered when obtaining such consent from parents. You can then compare your list with the elements we identified in the research project.
Parental consent must be sought since mobility and independence education often takes place outside of school grounds and includes activities which are not typical of a school day, and therefore there are safety and insurance implications. A further reason why it is important to obtain parental consent, is that it is an opportunity to raise parents’ awareness of their child’s needs and why mobility and independence support is important, and to recruit them into the process, so that they will take on responsibility.
A useful summary then, of the key elements of obtaining parental consent is as follows:
- It should be in writing
- It should give consent for children to take part in activities related to mobility and independence on an ongoing basis
- A single agent should obtain this consent (in the event of a multi-agency team)
Meeting with parents to explain the request for consent should be an option
- Awareness raising and recruitment into the process can be coincided with consent request
- The referral process should be linked to the request for consent – e.g. attaching an appropriate consent form to the referral documentation.
Guidelines and good practice
Activity 6
We list below a number of key features which we identified within the research project as examples of ‘good practice’ in the referral process. You may wish to use these as the basis for an audit tool to evaluate the extent to which the provision offered by your own service, or a service known to you, matches each of these features.
Children should be referred at key times. These should include:
- After initial diagnosis of the visual impairment (this would include pre-school children)
- On entry to nursery/reception if child attends
- On entry to compulsory state education (at age 5)
- At transition periods of moving to a new school e.g. from primary to secondary, relocation
- On leaving secondary school or the education system, in liaison with other agencies if they will take over responsibility for mobility and independence support.
Ideally an assessment should be carried out within each key stage of their school career. Responsibility for making referrals needs to be clarified with all key people. Awareness raising should play a part in this, not only by the mobility and independence educator but in conjunction with the broader education service:
- Parents need to understand what mobility and independence is all about, and their role throughout the process (not just in referral). The QTVI/mobility and independence educator should take a lead in communicating with the family, preferably in person. Obtaining parental consent presents an ideal opportunity to do this.
- QTVIs need to have a level of awareness about possible mobility and independence issues so they can correctly identify them. INSET should play a key role here, along with ongoing liaison between them and the mobility and independence educator, and the use of referral forms and checklists.
- Class teachers and teaching assistants who have contact with a child who is visually impaired should also undergo some form of training from the mobility and independence educator to raise their awareness of mobility and independence issues.
- Health professionals including consultants, community paediatricians and health visitors should also receive awareness training (possibly in the form of literature), along with liaison with the mobility and independence educator/QTVI.
- Referral routes should be clear; one person within the education service should be designated as the receiver and co-ordinator of all referrals.
- The referral route should be clearly defined and described in the mobility and independence policy held by the education service, which should be made available to all concerned agencies (social services, health service, voluntary organisation, etc).
Activity 7
If you are currently involved in providing M&I education, think about how children are referred to the service.
If they are reactive referrals, what disadvantages might there be? Try to think of ways that automatic referrals could be introduced alongside the reactive system. Who would need to be involved in the process, and what additional resources might be needed?
Who makes referrals to the service? Could other people make referrals, and if so what training or information would they need?
What are the benefits of using a referral form, and does your service provide one?
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