Evaluation of special educational needs and disability provision in English primary schools using administrative health and education data in the ECHILD database

Abstract

Introduction
Schools worldwide balance whole-class teaching with additional provision for children with special educational needs or disability (SEND). Robust evidence on equity and effectiveness of SEND provision is essential to address growing demand and rising costs globally.

Objectives
To synthesise findings from the Health Outcomes for young People throughout Education (HOPE) evaluation of variation in SEND provision and its impact on health and education outcomes in English primary schools. We integrated findings from 14 sub-studies using administrative data in the Education and Child Health Insights from Linked Data (ECHILD) database and 10 mixed methods sub-studies.

Methods
Analyses of ECHILD data followed children from birth to age 11 years. We examined how variation in SEND provision was associated with health conditions, and school, social and organisational factors. Using target trial emulation, we estimated the impact of SEND provision on hospital admissions, school absences and attainment. We surveyed and interviewed young people, parents, and professionals and reviewed information about services to understand SEND processes and contexts.

Results
Of 3.8 million children born 2004 to 2013, 30% had SEND provision recorded by age 11. Health conditions were only partially associated with SEND provision, which was also related to male gender, social disadvantage, low attainment and type of school. SEND provision modestly reduced rates of unauthorised absences in subgroups of children but showed no measurable benefit on hospital admissions or school attainment. Mixed methods studies highlighted benefits of early, responsive support, challenges posed by limited capacity, harms caused by delayed or inadequate provision, and need for parent advocacy to access SEND provision.

Discussion
Weak evidence of benefits of SEND provision in causal analyses likely reflects unmeasured confounding, lack of measures of provision received and insensitive outcomes in ECHILD data. SEND policies need robust evidence from analyses across jurisdictions using administrative data, enhanced with better measures, experimental methods and contextual evaluation.

Background

Special educational needs

Education systems worldwide need to balance delivery of effective mainstream education with additional activities or support for children who experience difficulties with learning compared to their peers [1]. In this study of the English context, we refer to such additional support as special educational needs or disability (SEND) provision (see Appendix 1, Table A1 Section 5) [2]. Typically, SEND provision involves a wide range of types and intensity of activities, from continuous one-to-one support to occasional group work, across various types of needs. Activities change as the child responds and develops [3]. SEND provision also includes collaboration between multi-sector professionals and families, all within a complex, publicly funded system [4, 5].

Children likely to need SEND provision include those with disability, preterm birth or chronic physical or mental health conditions that affect learning [5–7]. In many countries, children with behaviour problems, speech or language difficulties, low school attainment, social disadvantage, and those who speak a different language are also assigned SEND provision [1]. Countries worldwide report rising demand and increasing costs of SEND provision, reflecting improved survival among children with medical conditions, increasing recognition of neurodevelopmental disorders, and global efforts to expand educational access and provide inclusive education for all [8–10].

Purpose of this report

This paper provides an overview of the Health Outcomes of young People throughout Education (HOPE) study and synthesises findings of sub-studies conducted by the programme [11]. The aim of the HOPE study was to examine variation in SEND provision in English primary schools and assess its impact on children’s health and educational outcomes articulated across four main questions [11]. We conducted 12 quantitative studies using linked health and education administrative data from the Education and Child Health Insights from Linked Data (ECHILD) database [12] and 10 mixed methods studies. Comprehensive descriptions of methods and results can be found in 30 papers listed in Appendix 4.

We organised the paper as follows. First, we summarise existing evidence on the effectiveness of SEND provision and outline SEND policy and practice in England. Second, we give an overview of the HOPE study questions and methods - including the ECHILD data resource and how we derived cohorts and synthesised findings. Third, we report findings for each of four research questions and present key findings. Fourth, we present our conclusions on variation in SEND provision and its impact on outcomes and discuss strengths and limitations of the study. We end by discussing challenges posed by administrative data relevant globally and the implications of our findings for policy and future research.

Existing evidence on the effectiveness of SEND provision

In England, SEND provision seeks to support four broad areas of functional needs: communication and interaction, cognition and learning, social, emotional and mental health, and sensory and physical needs [13–15]. These needs often arise from physical or mental health conditions or from social contexts that affect areas of child development [5, 6, 16, 17]. High quality SEND provision has the potential to improve health and education outcomes in childhood, and thereby health and wellbeing in adolescence, with long-lasting impacts on health and economic inequalities in adulthood [6, 18–20]. However, evidence for effective SEND provision is mixed.

On the one hand, an international systematic review of 467 comparative studies of children with known additional needs (including 297 randomised controlled trials; RCTs), reported consistent beneficial effects of different types and durations of SEND activities compared with service as usual or alternative education activities [4, 21]. On average, these benefits equate to 5 to 6 months of improved learning in maths, reading, or related skills. Most studies included in the review were focused on targeted activities for well-defined learning difficulties (e.g. 40% were for dyslexia), rather than evaluating SEND provision across the breadth of usual practice [22]. In addition, the impact of these targeted interventions, assessed under controlled research conditions, may not generalise to the complex, interdependent processes through which SEND provision operates in real-world school settings. Few studies have accounted for the underlying health conditions and health inequalities that shape both the need for, and the outcomes of, SEND provision.

Evidence for the effectiveness of SEND provision as delivered in schools is more limited than the evidence base for targeted interventions. SEND provision as a service involves a variety of interventions for a wide range of different needs. The delivery of SEND services intersect with socioeconomic position and family factors, health, social care services, and local service capacity. Such complex processes are hard to evaluate. So far, limited evidence of benefit has been reported by numerous observational studies over the past 25 years. As expected, descriptive studies found that children assigned SEND provision had worse outcomes than peers, due to confounding by higher underlying health and education needs [16, 22, 24]. However, 49 studies that attempted to account for confounders using quasi- or natural experimental designs, also found no difference or worse outcomes for children assigned SEND provision [22, 23, 26–30]. Similarly adverse findings were reported in an evaluation of teaching assistants in England, a group who are typically involved in delivering SEND provision [31].

Recent advances in causal methods are presented as a framework for using natural experiments, also called quasi-experimental methods, to evaluate population health interventions [32, 33]. The framework refers to a range of methods to achieve comparability (or exchangeability) between those with and without intervention. Various methods can be used to account for measured confounding, including those within the target trial emulation framework (TTE) [32, 34]. Methods often used to address unmeasured confounding include difference-in-difference and instrumental variable techniques. A meta-analysis of 44 U.S. studies that tried to minimise confounding found eight studies that addressed the bias arising from unmeasured confounding [28]. These studies used policy changes [35, 36], or changes within children’s SEND status over time [37, 38], or differential SEND thresholds across racial groups, in natural experiment approaches [35, 39, 40]. All eight found effects of SEND provision: five reported beneficial impacts, while three reported harmful effects for certain subgroups. For example, two studies found worse outcomes for children who were just below the threshold for SEND provision who received provision due to policy changes [39, 40, 41]. These effects for marginal groups might not be generalisable to all children who need SEND provision.

In summary, uncertainty remains about the benefits of SEND provision as delivered in routine practice globally, as well as in England. At the same time, there is strong evidence that targeted activities, delivered as key elements of the SEND process, are effective, albeit often for narrowly defined needs and outcomes [9]. Policy makers need robust evidence on what types of SEND provision work, for whom, and under what conditions, and on the effectiveness of the overall SEND process, to deliver effective support while containing costs. Applying robust study designs to linked administrative health and education data provides a unique opportunity to fill these evidence gaps.

SEND policy and provision in England

Despite the uncertain evidence [2, 42], England has seen major policy changes to funding and delivery of SEND provision over recent decades, which offer opportunities for natural experiment designs that address unmeasured confounding. Since 2001 [43], policy has shifted towards inclusion of children receiving SEND provision in mainstream education. The Children and Families Act (2014) [2], and the SEND Code of Practice (2015) [3], aimed to improve SEND joint working with health and social care services and devolved decisions and funding for less intensive SEND provision to schools. However, schools were challenged by a more competitive, attainment-focused, marketisation of education that disincentivised inclusion of children unlikely to perform well in attainment tests. In 2022, a House of Lord’s review of the 2014 Act concluded the government had ‘ultimately failed’ to improve outcomes, due to failure of implementation [44].

Implementation of the 2014 Act coincided with two broader system shifts. Austerity-related cuts to local authority (LA) budgets from 2010 reduced SEND and social care funding, and expansion of academy schools from 2007 drove competition between schools and widened inequalities in SEND provision between schools [8, 45]. Analyses using English primary school education data showed that the primary school a child attends is a stronger predictor of SEND provision over any personal or family characteristics [25].

SEND provision affects a substantial minority of children in England. One-third of all children in state school in Year 1 in 2005/6 had been assigned SEND provision by age 16 [11]. Approximately 30% of all children were assigned SEN Support, which is determined and delivered by schools. Since then, between 3-5% of all children have been assigned an Education, Health and Care Plan (EHCP), which is assessed, approved and part-funded by local authorities (Appendix 1 Table A1, Section 5) [3]. SEN Support typically includes in-class assistance, teaching aides or adaptive learning, while EHCPs provide tailored and personalised support for more complex needs. Approximately half of all children who receive an EHCP attend a special school [3]. Since 2010, the proportion receiving SEN Support has declined, while use of EHCPs has risen steadily since 2016, driving annual SEND expenditure in England above £11 billion in 2025 [8, 42]. Further reforms to the SEND provision system will be published by the Department for Education (DfE) in 2026 [46, 47].

Overview of methods used in the HOPE study

Research questions and approach to synthesis

The HOPE study aimed to examine variation in SEND provision in English primary schools and assess its impact on children’s health and educational outcomes [11]. We addressed four main research questions and consulted with young people, parent-carers and professionals throughout the study (Appendix 2):

Question 1: Which health conditions (phenotypes) are associated with outcomes that might be improved by SEND provision?

Question 2: What factors influence who is assigned SEND provision, and when and where this occurs?

Question 3: What is the impact of SEND provision on health and education outcomes?

Question 4. What do service experiences and policies tell us about the process and delivery of SEND provision?

We used the ECHILD (Education and Child Health Insights from Linked Data) database to address the first three questions and mixed methods studies to address the fourth (Figure 1). Details of data resources are in Appendix 1, Table A1, sections 4-6.

Figure 1: Diagram of data sources used to address the questions posed by the HOPE study.

We synthesised findings from the sub-studies addressing the four research questions through an iterative process. First, researchers integrated findings within each individual question. Then, teams working on each question shared their results throughout the study to summarise common and contrasting emerging themes across all four research areas and to identify issues for further discussion with stakeholders (see Appendix 2). We generated conceptual diagrams to map findings between studies (e.g. Figure 7). In the final stage of synthesis, we met public and professional and government stakeholders to discuss the implications of findings (Appendix 2).

The ECHILD Database

The HOPE study used the ECHILD data database for the 12 sub-studies addressed by research questions 1 to 3 listed above. The ECHILD database links routinely collected health and education data in England. For the HOPE study we used ECHILD version 1, which includes all children and young people aged 0-24 years who were born in a state-funded hospital between 1 September 1995 and 31 August 2021 (approximately 14.7 million individuals) [12]. Health and education datasets were linked by National Health Service (NHS) England using a multistep deterministic linkage algorithm [48]. Linkage rates were high and increased overtime (92% of school pupils born in academic year 1990/1991 were linked to a hospital record, compared with 99% of pupils born in 2004/2005) [48].

Health data from the Hospital Episode Statistics (HES) database includes records of all NHS-funded hospital care in England. We created birth admission cohorts from 1 September 2003 onwards as linkage to subsequent admissions, outpatient appointments and accident and emergency attendances was high from this point onward. HES admissions include birth records for approximately 97% of all children who are born in NHS facilities and captures an estimated 98–99% of all secondary care contacts [11, 49, 50]. HES records contain demographic details (e.g., sex, ethnic group, area of residence) and admissions data include clinical information based on International Classification of Diseases, 10th Revision (ICD-10) diagnostic codes and Office of Population Censuses and Surveys, 4th Revision (OPCS-4) procedure codes [50].

Education data from the National Pupil Database (NPD) capture information on children attending state-funded schools in England from the 2001/02 academic year onwards [51]. The NPD includes pupil registration, attainment, exclusions, and absences, alongside individual- and school-level characteristics such as local authority, ethnicity, gender, Index of Multiple Deprivation (IMD), English as a first language, free school meal eligibility, social care involvement, and SEND status [11, 51]. Further details are in Appendix 1, Table A1, Sections 4–6.

Birth cohorts in the HOPE Study

Ten birth cohorts were constructed from ECHILD to meet the specific analytic needs of each sub study (Table 1; Appendix 3). Sub studies used longitudinal designs and spanned multiple academic primary school years (eg: 1 September 2003 to 31 August 2004) onwards [11, 51]. Follow-up periods were defined according to each study’s objective, exposure group and educational variables of interest and data availability. For example, data access for cohort 4, which was analysed at the start of the study, was limited to births in 2004/5 [52].

Table 1: Details of ECHILD-derived cohorts used in HOPE sub-studies* grouped by research question (see Appendix 3). Y1: Year 1. *Further details can be found in Appendix 4. **Data access for this cohort used in early work was restricted to one year. ***Cohorts 8, 9 and 10 are restricted to children with the phenotype only. All other cohorts include children with phenotype and unaffected peers.

Cohort Number	Population of Interest	Details
Q1: Which health conditions (phenotypes) are associated with outcomes that might be improved by SEND provision?
1	Neurodisability	6 birth years (2003/4–2008/9) No school linkage N = 3,580,225
2	Neurodisability	6 birth years (2003/4–2008/9) Y1 school entry N = 2,956,299
3	Neurodisability, Congenital Anomalies	5 birth years (2003/4–2007/8) Reception school entry N = 2,351,589
4**	Gestational age across whole population	1 birth year (2004/5) Reception school entry N = 306,717
Q2: What factors influence who is assigned SEND provision, when and where?
2	Neurodisability	As above
3	Gestational age**	As above (used for Figure 3
5	Congenital Anomalies	11 birth years (2003/4-2013/14) Y1 school entry N = 5,189,922
6	Whole population (excluding births before 34 weeks of gestation)	11 birth years (2003/4-2013/14) Y1 school entry N = 3,729,265
7	Whole population	2 birth years (2006/7–2007/8) Nursery 1 entry N = 983,652
8	Cerebral Palsy only***	10 birth years (2003/4-2012/13) Nursery 1 entry N = 5,669
Q3: What is the impact of SEND provision?
	Cerebral Palsy only***	11 birth years (2003/4-2013/14) Y1 school entry N = 3,275
	Cleft Lip and/or Palate only***	11 birth years (2003/4-2013/14) Y1 school entry N = 6,601

Most analyses using educational outcomes up to the end of primary school (Key Stage 2, aged 10-11 years) restricted birth years to the end of the 2007/8 academic year (31 August 2008). This ensured that all children had finished primary school before the COVID-19 pandemic which disrupted attendance, learning and assessments [53]. The January school census was used to identify children enrolled in each academic year, as this census determines school funding allocations and is therefore considered the most complete record of pupil enrolment [54].

Synthesis of findings

Question 1: Which health conditions or phenotypes are associated with outcomes that might be improved by SEND provision?

The first step of the HOPE study involved developing high-need health phenotypes to proxy groups of children likely to need SEND provision. This step is critical, as education data captures only the assignment of SEND provision but no indicators for the underlying need for additional support. Using external evidence, clinical input and insights from ECHILD data regarding the reliability of diagnostic coding in administrative data, we chose three groups of health phenotypes which capture populations with different levels of need for SEND provision: neurodisability [55], congenital anomalies [56], and preterm or early term births, defined by week of gestational age [52, 57]. These phenotypes were mainly recorded before school entry and, on average, were expected to have mild to moderate (congenital malformations) or moderate to high (neurodisability) need for SEND provision or a gradient of need by week of gestational age at birth. We described outcomes for each of these phenotypes, including variation between subgroups within each phenotype. Combinations of neurodisability and other high need health phenotypes were described for children with Down syndrome. In addition, we grouped children with any chronic health conditions in analyses of factors that influence SEND provision (Question 2, Table 1 cohorts 6,7).

We assessed health and education outcomes for children with high-need phenotypes and unaffected peers, from school entry to Year 6 (age 11) using cohorts 1 to 4 (Table 1) [52, 58–60]. Outcomes included: mortality before school start, comorbidities, planned and unplanned hospital admissions, unauthorised school absences, and whether a child reached the expected level of development, based on school test scores at ages 5, 7 and 11 (Appendix 1, Table A1. Section 6.6)

Children in each of the three high need health phenotype groups had more unplanned admissions [59, 61], more comorbidity [55, 62], more frequent absences [61], and lower attainment [58, 60, 63, 64], than their unaffected peers. As expected, there was substantial variation between phenotype subgroups (Appendix 4, papers 2-10). We illustrate these patterns by summarising results for children with neurodisability. Of 3.58 million children, 2.4% had a hospital-recorded neurodisability before age 5, rising to 3.6% by age 11 (Cohort 1) [55]. These children were admitted to hospital five to seven times more often than their peers and accounted for 15% of all hospital bed-days during primary school (for the 2.96 million children who had linked education records in primary school in Cohort 2) [61]. We also found 60% higher school absence rates and consistently lower attainment during primary school among children with neurodisability [61, 63]. At age 5, only 30% of children with neurodisability before school entry reached a ‘good level of development’ (GLD), compared with 58% of peers, and fewer than half met expected levels at ages 7 and 11 (Figure 2a) [63]. By the end of primary school (Figure 2a, Key Stage 2), over a third of children with neurodisability were not assessed in national attainment tests, contrasting with 6.4% of unaffected peers enrolled in school [63]. Outcomes varied significantly by neurodisability type and in each phenotype subgroup (Figure 2b) [63].

Figure 2: Proportion of children with and without hospital-recorded neurodisability by age 5 (and subgroups) achieving nationally expected levels across primary school assessments (Cohort 3).

Children with congenital anomalies comprised 3.5% of 2.35 million children entering primary school (Cohort 3). Attainment varied between subgroups, with the lowest average attainment through primary school occurring among children with chromosomal or neurological congenital anomalies [64]. Average differences between children with and without congenital anomalies were small to moderate [64]. We found lower attainment across all anomaly subgroups for boys than girls [64]. Separate analyses of the whole population (Cohort 4) revealed lower attainment for each week of gestational age at birth before and after 40 weeks of gestation (Figure 3) [52].

See key findings, Table 3.

Figure 3: Proportion of children assigned SEN Support or an EHCP ever during primary school by week of gestation (Cohort 3) born 2003/04 to 2007/08). EHCP: Education and Health Care Plan; SEND: Special Education Needs and Disabilities; SEN Support: special education needs Support

Question 2: What factors affect who is assigned SEND provision, and when and where this occurs?

Who?

We followed cohorts of children with neurodisability, congenital anomalies and their unaffected peers, and children grouped by week of gestational age at birth (cohorts 2,5 and 4 in Table 1) to determine the proportion of children with any SEND provision (SEN Support and/or an Education, health and care plan - EHCP) recorded in Year 1 (age 5/6) and up to the end of Year 6 (age 10/11) [52, 55, 56]. The proportion assigned SEND provision was consistently higher among children with any chronic health condition or born preterm compared with their unaffected peers [55, 56]. Children with neurodisabilities had the highest proportion: 76% had any SEND provision recorded ever during primary school and 40% had an EHCP [55].

Substantial variation in the proportion of children with SEND provision was observed across condition-specific subgroups within the neurodisability and congenital anomaly phenotypes, and by week of gestational age at birth (Figure 3) [52, 55, 56].

EHCP: Education and Health Care Plan; SEND: Special Education Needs and Disabilities; SEN Support: special education needs Support.

We found that children with any recorded chronic health condition were more likely than peers to have SEND provision. In analyses of the whole population of children (Cohort 7, born 2006/7 to 2007/8), 18.1% of all children had at least one chronic health condition recorded; among these, 26.6% received any form of SEND provision and 5.9% had an EHCP in Year 1. The corresponding proportions with SEND provision among those without a chronic health condition were 13.4% and 0.7%. Despite this strong association, children with chronic health conditions recorded during a hospital admission accounted for only 30.5% of all children with any SEND provision and 63.9% of those with an EHCP in Year 1 [65]. These figures exclude children with chronic health conditions managed in the community without hospital admissions. Factors other than health conditions also influenced SEND provision. Socio-demographic factors were strongly associated with any SEND provision and with SEN Support: being a boy, the youngest in class (i.e. summer-born children) and being from a disadvantaged background, as measured by free school meal eligibility, young motherhood, and residence in the 40% most deprived areas. Associations between EHCP assignment and social disadvantage were weaker and less consistent, although the association with male gender remained strong [65].

When?

We classified the stage at first entry to state education as either state-provided Nursery (school-based or local authority (LA) provided at age 2-4 years, N1 and N2), or state primary school Reception class (age 4/5) or Year 1 (age 5/6). We used data from the whole population of children born between September 2006 and August 2008 (Cohort 7). Overall, 42% of children began state-provided education in Nursery while 57.6% entered directly into Reception [65]. Children starting in Nursery had higher levels of chronic health conditions and social disadvantage, consistent with the socioeconomic eligibility criteria for accessing free nursery places at ages 2 to 3 [65, 66].

Using longitudinal data for the same cohort, we calculated the percentage of children assigned SEN Support or EHCP provision each year according to year of entry to state-funded education (including state-funded hours in private nursery provision) up to Year 6 (age 10/11). This percentage was highest among those entering state-provided education in Nursery and among the small group (0.4%) entering in Year 1, and lowest among those entering in Reception (Figure 4; note Year 1 entrants not shown to avoid small numbers). The proportion assigned SEN Support increased gradually, peaking in Year 2, before levelling off. In contrast, the proportion with an EHCP remained low (<5%) and rose only slowly throughout primary school [65]. For analyses of group characteristics of child who continued, started or stopped SEND provision between Year 1 and 6 see separate report [65].

Figure 4: School year percentage of children assigned SEN Support or EHCP provision during state-funded hours in Nursery or state Primary school (up to Year 6) according to stage at entry to state-provided education; Cohort 7 (born 2006/7 to 2007/8). N-SEN Sup: Percentage of children assigned to SEN Support in each academic year among those who entered state-provided education in Nursery; R-SEN Sup: Percentage of children assigned to SEN Support in each academic year among those who entered state education in Reception; N-EHCP: Percentage of children assigned to EHCP in each academic year among those who entered state-provided education in Nursery; R- EHCP: Percentage of children assigned to EHCP in each academic year among those who entered state education in Reception. The percentage of children in each academic year who were assigned SEN Support or EHCP are shown by stage at entry into state-provided education. N-SEN Sup and N-EHCP refer to children entering state-provided education in Nursery and R-SEN Sup and R-EHCP refer to those entering in Reception class. The small proportion (0.4%) entering in Year 1 is not shown. As SEND provision during state-funded hours in a private or voluntary nursery is included, children entering state-provided education in Reception can have SEND provision earlier [65].

We further explored the timing of SEND provision by analysing high-need children with cerebral palsy recorded in hospital admission records before entering state education (Cohort 8) [67]. We employed a staggered cohort design to account for differences in stage at entry into state education. At each stage at entry to education, and across combinations of sociodemographic variables (gender, neighbourhood deprivation and free school meal status), we estimated the average cumulative probability of any SEND or EHCP provision by year from Nursery to Year 6, using inverse probability weighted logistic regression.

Our analysis found no differences in EHCP probability by free school meal eligibility, but there was evidence of delayed EHCP provision for those living in the poorest neighbourhoods [67].

Time period is another factor influencing SEND provision. We assessed whether the Children and Families Act (2014) [2], enacted through the SEND Code of Practice (2015) [3], was associated with measurable changes in provision in Year 1 (Cohort 6, born 2003-14; Figure 5) [56]. Between academic years 2009/10 and 2018/19, the prevalence of SEND provision declined steadily among children with major congenital anomalies and their unaffected peers. Among unaffected children, the proportion recorded to have received any form of SEND provision in Year 1 fell by 4.2% after 2014, and by 4.8% for those with congenital anomalies [56]. There was no observable step change following the 2014 SEND reforms, thereby limiting the potential to exploit the legislative change as an instrumental variable in a natural experiment evaluating the impact of SEND provision [32].

Figure 5: Percentage of children assigned to any SEND provision in Year 1, by academic year and major congenital anomaly (MCA) status; Cohort 5 (born 2003-14). MCA: major congenital anomalies; Black line: percentages for all children; Grey line: percentages for children without MCA; Brown line: percentages for children with MCA.

Where?

Schools and LAs make decisions about SEND provision [3], but how schools are governed has changed considerably since 2007, with autonomous academy schools becoming more prevalent [68]. We assessed whether the type of school governance in Year 1 influenced SEND provision in the same year by analysing the experience of Cohort 7. School governance affects admissions policies, teaching about faith, and staff employment (Appendix 1, Table A1, Section 2). A shift to more autonomous schools, not controlled by the LA, has been progressing since 2007 [68]. We plotted the observed probabilities for any SEND, SEN Support or EHCP provision by school type. We then estimated equalised probabilities by controlling for (and then averaging over): the stage at entry to state education (Nursery, Reception, or Year 1), chronic health conditions, preterm birth, social disadvantage, demographic factors prior to stage at education entry and the EYFSP developmental score at age 5 [65]. We found substantial variation in the probability of SEN Support or EHCP provision in Year 1 across these different types of school governance [65]. Voluntary aided and voluntary controlled schools – typically religious schools – had the lowest rates of SEN Support and EHCP provision and academy sponsor-led and community schools had the highest rates (Figure 6). Variation diminished after equalising populations according to child-level differences in health characteristics, sociodemographic, stage at entry, and expected levels for the EYFSP assessment at age 5, but voluntary and academy sponsor-led schools had a lower probability of EHCP provision than community schools [65].

Figure 6: Observed and equalised* probability of (a) SEN Support and (b) EHCP provision by school governance (Cohort 7, born 2006-08). SEN: Special education needs; EHCP: Education and Health Care Plan; VA: Voluntary aided; VC: Voluntary Controlled; Acad Spons: Academy Sponsored; Acad Conv: Academy Converter; CI: confidence interval. The pink dots (with respective 95% confidence intervals) represent the observed probabilities for SEN Support (in part (a)) and EHCP (in part (b)) provision by school type; The blue dots (with respective 95% confidence intervals) represent the estimated equalised probabilities of, respectively, SEN Support and EHCP. These were obtained by fitting logistic regression models for SEN Support and EHCP that included: the stage at entry to state education (Nursery, Reception, or Year 1), chronic health conditions, preterm birth, social disadvantage, demographic factors prior to stage at education entry and the EYFSP score at age 5. The predictions from these models were then averaged over these features to obtained what we call ‘equalised’ probabilities, i.e. probabilities that would be observed if all schools had the same pupil characteristics (Appendix 4, paper 15) [69].

In separate analyses, we also assessed whether the LA of residence, which is responsible for funding and assigning EHCPs, influenced the probability of a child being assigned SEND provision using three subgroups of children from the extended whole cohort of children born in 2003 to 2014 (Cohort 6) [69]. Subgroups were defined by gestational age groups expected to have diminishing need for SEND provision: late preterm (34–36 weeks), early term (37–38 weeks), and full term (39–41 weeks). We quantified variation between LAs in the probability of receiving SEN Support, EHCP or any SEND provision in Year 1, by estimating the intraclass correlation coefficient (ICC) at each stage of multilevel models that controlled for child level health, social and demographic factors, EYFSP score age 5, school type (mainstream or special) and school governance [69]. After adjusting for child-level variables, only a small proportion of the variation was attributable to differences between LAs: it ranged from 2.0% for SEN Support (vs none) to 5.8 percent for EHCPs (vs SEN Support) across gestational age subgroups. Including LA income deprivation in the model reduced the variance in EHCP provision by up to 24 percent [69].

See key findings, Table 3.

Question 3: What is the impact of SEND provision on health and education outcomes?

We planned to use two quantitative approaches to evaluate the impact of SEND provision on health and education, i.e. to perform causal analysis. Both approaches are within the natural experimental framework [32]. The first approach involved assessing whether observed changes in policy, or differences in practices between schools or local authorities, introduced sufficient exogenous variation to enable the use of instrumental variable methods for the estimation of the impact of the new policies (see Appendix 1, Table A1 Section 3 for definitions). These methods can account for unmeasured confounding [32]. The second approach used the target trial emulation (TTE) framework to define causal questions that could replicate an ideal RCT with observational data [70]. The framework requires defining the causal contrasts of interest, the exposure (SEND provision), the relevant outcomes and confounders. Principled methods to deal with measured confounding, such as propensity score-based and g-methods are then adopted (under the additional assumptions of no interference, consistency and positivity). By making all elements of the causal question explicit, the TTE framework helps to minimise biases, for example, due to misalignment of study entry, eligibility and exposure assessment, or to incorrect assignment of later exposure status to an earlier period [71].

Our analyses for question 2 did not reveal any suitable instrumental variables to support the first approach. We therefore evaluated the impact of SEND provision using the TTE framework. We focussed on two sub-phenotypes of children: those with cleft lip with palate and those with cerebral palsy (Cohorts 9 and 10) [72, 73].

We chose cleft lip and/or palate as a phenotype likely to reflect mild to moderate need for SEND provision, because average differences in education and health outcomes between affected children and peers are small (Cohort 9) [72]. The cerebral palsy phenotype was chosen to proxy high need for EHCP provision using specific codes for cerebral palsy (Cohort 10) [73]. For each cohort, we iteratively refined the phenotype to increase similarity in need by excluding children with anomalies affecting other body systems. Outcomes were unplanned hospital admissions, unauthorised school absence in Years 2-6 and attainment in mathematics in Year 2 (age 6/7) and Year 6 (age 11).

We estimated the impact of SEN Support in Year 1 versus none for both phenotypes, and EHCP versus SEN Support in Year 1 (for cerebral palsy) on unplanned admissions, unauthorised absences and key stage test scores through primary school, Other comparisons were not possible because of lack of positivity [72, 73].

We found no evidence that SEN Support in Year 1 compared with none improved rates of unplanned hospital admissions or educational attainment in either the cerebral palsy or the cleft lip and/or palate phenotype subgroups. Findings were similar for EHCP vs SEN Support for children with cerebral palsy, except for reduced unauthorised absences (Table 2) [72, 73]. There was evidence that SEN Support compared to none reduced the rate of unauthorised absences for both phenotype groups (Table 2).

Table 2: Summary of findings of causal analyses to estimate the impact of SEND provision on health and education outcomes (Question 3; cohorts 9, 10) [72, 73]. EHCP: Education and health care plan; SEND: special educational needs and disabilities; SEN Supp : special educational needs Support; KS1: Key Stage 1; KS2: Key Stage 2; Ref: reference category.

Phenotype and compared interventions in Year 1	Unplanned admissions Year 2–Year 6	Unauthorised absences Year 2–Year 6	KS1 Year 2	KS2 Year 6
Cleft lip and/or palate
(Cohort 10)
SEND Supp vs No Support in Year 1 (Ref)	No difference	Better in SEN Supp	Worse in SEN Supp	Worse in SEN Supp
Cerebral palsy
(Cohort 9)
SEND Supp vs No Support in Year 1 (Ref)	Worse in SEN Supp	Better in SEN Supp	Worse in SEN Supp	No difference
EHCP vs SEND Support in Year 1 (Ref)	Worse in EHCP	Better in EHCP	No difference	Worse in EHCP

The findings of improved and worse outcomes in Table 2 should be interpreted with caution given the likely impact of residual confounding arising from the coarseness of the measures available in ECHILD. Furthermore, our choice of outcomes was limited by the accuracy and relevance of data available. For example, absences may be less likely recorded as unauthorised for children with an EHCP. Also, other outcomes relevant to learning or socio-emotional skills may not be captured in ECHILD [72, 73].

See key findings, Table 3.

Table 3: Key findings from the HOPE (1) study. 1. HOPE Study: Health Outcomes for Young People Throughout Education; 2. SEND: Special Educational Needs and Disabilities; 3. SEN: Special Educational Needs; 4. EHCP: Education and Health Care Plan; 5. Local Authority; 6. SENCO: Special educational needs coordinator.

1. Which health conditions (phenotypes) are associated with outcomes that might be improved by SEND2 provision?

- Children with neurodisability, congenital anomalies, or preterm birth had more unplanned hospital admissions and more frequent school absences and lower attainment at age 7 and 11 compared to unaffected peers.

- These outcomes were on average worse for children with neurodisability than for children with congenital anomalies or those born preterm.

- Outcomes varied substantially between specific condition subgroups within each phenotype, and by week of gestational age at birth.

2. What factors influence who is assigned SEND provision, and when and where this occurs?

a) Who is assigned SEND provision?

- Children with greater health needs, boys, summer-born pupils, and those from disadvantaged backgrounds were more likely to receive SEN3 Support or an EHCP4.

- Rates of SEND provision were highest among children with neurodisabilities but hospital recorded conditions were inadequate proxies for the need for SEND provision.

b) When is SEND provision assigned?

- The probability of being assigned SEN Support or an EHCP increased only gradually from Nursery onwards, peaking in Year 2 for SEN Support and in Year 6 for EHCP

- Children who started in state Nursery were more likely to receive SEN Support or an EHCP throughout primary school than those starting in Reception.

- Among children with cerebral palsy, 95% received SEN Support and 72% had an EHCP by the end of primary school.

- SEND provision in Year 1 declined gradually from 2009/10 to 2018/19 with no appreciable step change when SEND reforms were introduced.

c) Where is SEND provision assigned?

- Type of school governance was associated with SEND provision. Voluntary and academy sponsor-led schools had lower probability of EHCP provision than community schools after accounting for pupil characteristics.

- Variation across Las5 was minimal and mostly explained by child characteristics and area-level deprivation.

3. What is the impact of SEND provision on health and education outcomes?

- No evidence was found that Year 1 SEND provision reduced hospitalisations or improved attainment.

- SEN Support was associated with reduced unauthorised absences compared with no support for cerebral palsy and cleft lip and palate, with additional reductions for EHCP vs SEN Support in cerebral palsy.

- As not all indicators of need are measured, unmeasured confounding may affect both null and beneficial effects of SEND provision.

4. What do service experiences and policies tell us about the process and delivery of SEND provision?

- Delays, inconsistent identification, and inequitable access to assessments were widespread, driven by workforce shortages, weak interagency coordination, variable LA practices, and increasing numbers of children with identified needs. EHCP processes were often inefficient, with limited parent and child involvement and poor communication.

- SEND provision was frequently delayed, poorly matched to needs, or lacking in aspiration. It relied heavily on parental awareness of services, advocacy and SENCO6 expertise. Timely, tailored support improved engagement and wellbeing, while inadequate provision harmed learning and mental health of children and other family members.

- Funding cuts, workforce pressures, and academisation led to variation in service quality and accountability. A narrow national curriculum assessed by exams was partly driving the increase in additional support needs, as well as limiting the chances for some SEND learners to succeed.

- Professionals called for clearer national standards, standardisation of key documents, stronger collaboration, and better resourcing to ensure equitable, effective provision.

Question 4: What do service experiences and policies tell us about the process and delivery of SEND provision?

We conducted ten mixed methods sub studies to understand experiences of the SEND process from the perspectives of young people and parent-carers using the service and from professionals contributing to SEND provision in some way [11]. We examined three core stages of the SEND process: noticing the need, SEND assessment, and implementation of provision. We explored outcomes of these processes for the child and family, and wider influences such as service capability and policies (Figure 7). The mixed methods sub studies included qualitative studies (interviews and focus groups), online surveys (with children, young people, parents/carers, and professionals) and document reviews of Ombudsman complaints, Ofsted/CQC inspection reports, Local Offer (LO) websites and grey and peer-reviewed literature on variation in SEND processes and provision at LA and multi-academy trust levels (Appendix 1, Table A1, Section 5). Appendix 5 summarises methods and key findings from each of the 10 sub-studies mapped to stages of the SEND process (identification, assessment, received provision), outcomes, local capability and policy.

Figure 7: Experiences of the SEND process, outcomes, and wider influences on local service capability to deliver services.

Initial identification

In qualitative studies, professionals reported increasing numbers and complexity of the need for SEND provision, linked to worsening poverty and in some settings, better identification by experienced Special Educational Needs Coordinators (SENCOs; Appendix 4, paper 26) [74, 80]. Parent-carers reported that quiet children, and autistic girls were frequently under-identified [74]. Online surveys found that 25% of children had been identified in pre-school and 47% by Key Stage 1. Parents reported negative experiences of identification, inadequate professional training, long waits, and limited specialist availability [75, 76]. While most professionals felt confident in identification, they mostly agreed that interagency communication was weak [77]. Document reviews revealed variation by multi-academy trust (MAT), SENCO level of experience, and LA [80]. Many Local Offer (LO) websites lacked clear, accessible criteria and process information [78].

Assessment and planning

EHCP processes were described in qualitative studies involving professionals as inefficient, due to poor interagency working, information sharing systems, and a lack of shared understanding of SEND provision and processes (Appendix 4, paper 26). Parents reported that high intervention thresholds and referral bounce-back harmed relations with families and left children unsupported, sometimes for years [74]. Surveys found fewer than one-quarter of parents reported adequate information at assessment; only half of children felt involved in decisions [75, 76]. Less than half of professionals reported that parents unable to advocate were adequately supported through the SEND process [77]. Document reviews highlighted weakened EHCP quality due to inconsistent application of Children and Families Act (2014) legislation, varying criteria for some SEND types, funding-driven allocation, poor co-production and involvement of children, poorly defined outcomes, and incomplete LO website eligibility criteria (Appendix 4, paper 26) [78, 80]. Poor quality EHCP processes and provision were common reasons for LAs failing inspections(Appendix 4, paper 22).

SEND provision

In the qualitative studies, we heard frequent reports of delayed and inappropriate SEND provision, harming children’s education and mental health. Tailored support depended on good SENCO training. Parent-carers acted as primary advocates but were excluded from LA decision-making panels. Appeals improved provision but were slow and costly; annual reviews were uncommon (Appendix 4, paper 26) [74]. Surveys found 75% of children wanted earlier support; only half reported inclusion in class that was similar to peers. Only one-third of parents said provision matched plans, and 41% said plans matched needs [75, 78]. Only 45% of professionals rated SEND provision as positive: their level of confidence was mixed in being able to deliver SEND provision or having the capacity to support families [77]. Document reviews indicated that LAs were frequently under-resourced for needs-led delivery [80].

Outcomes

Young people and parent-carers commented in qualitative studies that timely, tailored provision improved academic engagement, anxiety management, and independence [74, 79]. Challenging unmet needs took a toll on parent-carer mental health and finances. Professionals sometimes set unduly low aspirations [74]. Transitions required careful management, and reliance on parental advocacy reinforced inequities (Appendix 4, paper 26) [74]. In surveys, only half of parents reported that EHCPs included future goals; only one-third found these appropriately ambitious [75, 78]. Document reviews associated poor provision with dissatisfaction, complaints, and disproportionate exclusions (Appendix 4, paper 28) [74, 78, 80].

Local service capability

Qualitative studies indicated capacity constraints due to workforce shortages, insufficiently trained staff, complex caseloads, funding deficits, inconsistent eligibility thresholds, and limited specialist availability. High-quality information systems improved interagency working but were rare (Appendix 4, paper 26) [74]. Surveys found low awareness of what SEND provision was available locally (the LO). High parent-carer dissatisfaction with LA assessment processes was reflected by 38% of parents reporting paying for private assessments [75, 78]. Document reviews confirmed variation in local capacity, leadership, funding, EHCP rates, consistency of processes and interagency working [80]. Nationally, there were increasing complaints to the Local Government and Social Care Ombudsman (LGSCO) in an increasing number of LAs (Appendix 4, paper 28).

National policy context

Qualitative studies found that a narrow curriculum, exam-focused assessment, academisation, rigid attendance policies, and specialist shortages undermined inclusion and set some children up for failure (Appendix 4, paper 26) [74, 79]. Educators were increasingly absorbed in mental health roles, reducing capacity for prevention (Appendix 4, paper 26). Professionals reported that insufficient funding and training reduced service functioning and capacity (Appendix 4, paper 26) [77]. Document reviews found that professionals wanted nationally standardised processes and guidelines to improve quality. National policies on academisation reduced oversight and accountability for poor school practices on SEND provision. Some reports commented that the SEND code of practice led to under-recording of need, reduced the supply of specialist teachers and did not ensure LA compliance with legal requirements on the LO [78, 80].

See key findings, Table 3.

Discussion

Variation in SEND provision

Nearly one-third (30%) of children who entered primary school were assigned SEND provision by age 11 in 2014-19. SEND provision was strongly linked to health characteristics such as having a chronic health condition, including neurodisability or a congenital anomaly, or being born too early. However, these characteristics alone were not sensitive indicators of SEND provision. Other factors, such as being male, facing social disadvantage, and a low developmental score at age 5, were also important.

When children were assigned SEND provision was complex. Children with social disadvantage or disability, which is linked to eligibility for state-provided nursery at age 2-3, had higher rates of SEN Support and EHCP provision throughout primary school than their peers. Despite this increased provision, many did not start SEND provision until Year 1 or 2 (age 5–7), possibly due to delayed recognition, lack of school capacity, or changing need as education became more complex. However, in analyses of children with cerebral palsy, we found that those entering state education in Nursery and living in the 20% most income-deprived neighbourhoods were assigned EHCPs later on average than those from less deprived neighbourhoods [67].

Which type of school children attended was associated with their chances of SEND provision. Children attending voluntary, religious schools and academy sponsor-led schools were less likely to be assigned an EHCP compared with community, foundation and academy converter schools [65].

Findings from ten mixed methods studies highlighted variability in services. Some children and families reported meaningful benefits from provision, however, interactions with services, delays and inadequately tailored interventions frequently included negative experiences, some experiencing long term harm. Qualitative studies and surveys revealed unmet need and delays in identification of need, assessment, planning and provision, that particularly affected disadvantaged children who did not have parent-carers who could advocate for them. Parent-carer, child and professional perspectives and document reviews reflected services that lacked capacity, training and specialist expertise. These findings also highlighted a system that interacted poorly with other weakened systems (such as Child and Adolescent Mental Health Services) and lacked national guidance and accountability. These problems were compounded by underfunding, academisation, and a narrow curriculum that was perceived to undermine inclusion of children’s diverse abilities.

Impact of SEND provision

We found weak evidence that SEND provision in Year 1 (age 5/6) reduced rates of unauthorised absences, but no evidence for reductions in hospital admissions or improved attainment during primary school. These equivocal results are consistent with 49 natural experiment studies worldwide that evaluated SEND provision as implemented in routine practice (see introduction) [22, 23, 26–30].

These quantitative findings were complemented by qualitative findings in the HOPE study from parent-carers and children using SEND services and professionals. Their reports indicated that timely, tailored provision improved academic engagement, anxiety, and independence for children. However, the stresses of the SEND process, including inappropriate or inadequate provision, were experienced as harmful by children and their families.

Strengths and limitations

Strengths of the HOPE study included exploration of the evaluability of SEND provision using different approaches to causal analyses using rich, longitudinal health and education data for all children in state-funded primary education in England captured in the ECHILD database. The value of combining mixed methods with quantitative methods for policy evaluation has been emphasised by Craig et al [32]. In the HOPE study, mixed methods and stakeholder engagement, alongside the quantitative analyses, were critical for understanding variation in the adequacy of SEND processes and the many elements that were not measured in administrative data.

Limitations centred on a data science problem: inadequate measures of the need for SEND and other confounders, limited information on the nature of the intervention, and insensitive or insufficiently relevant outcomes that might not be measurably changed by SEND provision. A further limitation was that we found no instrumental variables to use in natural experiment designs that address unmeasured confounding, despite major changes in national SEND policy and types of school over the past two decades. These limitations undermined the evaluability of the impact of SEND provision on health and education using quantitative analyses of ECHILD.

Challenges and opportunities in using administrative data

Our findings reflect challenges that are relevant to other jurisdictions that use administrative data to evaluate SEND provision. One lesson from the HOPE study is that health phenotypes as recorded in hospital data do not adequately proxy need for SEND provision. Linked hospital and education data lack direct measures of function, disease, severity or complexity of need, and social and behavioural factors linked to high need for SEND provision and worse outcomes [81].

Secondly, SEND provision recorded in ECHILD reflects assignment to the SEND process but not what activities or support were received, at what intensity and when. Young people and parent-carers reported frequent delays in receiving support, watered-down activities or activities the child did not tolerate, due to lack of capacity, skills or ability of staff to adapt activities to the child.

Third, the outcomes measurable in ECHILD - hospital admissions, attainment test results and school absences - are relatively insensitive to positive changes reported in response to SEND provision by parent-carers and young people. They mentioned feeling happier, less anxious or distressed, improved sense of self, behaviour and mental health, and being able to attend school, participate, learn and socialise. Impacts on parent wellbeing were also mentioned, while reduced hospital contacts for the child were not.

Data linkage to relevant information from administrative, cohort, survey, trial or audit data on need for, and content of, SEND provision, and on relevant outcomes, could mitigate these three challenges. Examples exist elsewhere. In Wales, researchers can access anonymised education data linked to primary care and hospital data, further enhanced with survey data on function and wellbeing in the HAPPEN cohort [82].

Fourth, the SEND process may have been harmful for some children and families. Our study spanned a period of national austerity, with cuts to education and related services, rising child poverty and need for SEND provision. These changes occurred in parallel to policy changes that incentivised academic attainment and reduced funding and accountability for progress among children with additional needs. Parents and practitioners reported erosion in the capacity or skills to deliver SEND provision of adequate quality. These problems created distrust between parents and school staff and undermined partnership working between staff, child and parent-carer.

Fifth, notwithstanding these limitations, the HOPE study illustrates the opportunities to inform policy makers, teachers, clinicians and families about children’s trajectories through health and education and into adolescence. Descriptive analyses while being essential to design causal analyses, also provided important information on expected outcomes and variation and inequalities in SEND provision.

Implications for policy

Achieving effective and equitable SEND provision is a policy challenge in many countries. SEND provision is an expensive and important service - £11 billion per year in England - with the potential to change the life opportunities of one-third of all children [8]. More effective and efficient services could improve experiences and outcomes for children and their families, limit escalating costs, and yield long-term benefits across public services as better supported, more independent and educated children with additional needs transition to adulthood. Broader policy changes are also needed beyond SEND provision, including broadening the academic curriculum to value and measure other forms of progress, including social and emotional skills. Beyond schools, better integration is needed between health and education services for children with additional health and social needs, and more support for parent-carers to reduce the toll on families.

Further reforms to SEND in the UK and elsewhere [8], need to be based on, and continue to generate, evidence of what works. Development of high quality linked data research infrastructure across education and other public services should be at the forefront of government’s research areas of interest. Government should plan to integrate primary care data into the ECHILD database, to provide more granular data on the health determinants and consequences of education for children with additional health needs.

Implications for research

Despite the hundreds of RCTs of targeted SEND interventions and, with this study, 49 natural experiment studies on the impact of SEND provision, uncertainty remains about what works for whom, in what contexts and how. Achieving effective SEND provision requires randomised trials of alternative approaches to SEND provision in situations where uncertainty exists and comparators are acceptable. For example, the HOPE study found that SEND is provided to few children in the general population in the preschool years (Nursery and Reception class). Although earlier implementation makes intuitive sense, and is provided for some disabilities such as visual impairment, there is limited evidence of benefit from contemporary nursery-based trials [83, 84]. A randomised, staggered trial should be considered to implement policy change in England and, at the same time, generate robust evidence on early versus deferred SEND provision in the early years [85].

Policy makers also need evidence on what good SEND provision and alternative practice options look like to develop meaningful evaluations of impact. Our mixed methods studies revealed a SEND service that few users experienced as being able to meet needs due to lack of funding, staff, skills, interagency support and trust from families [42]. Comparison of such a weakened system of SEND provision against education as usual is unlikely to advance policy.

More and better research is needed to guide development of effective and equitable SEND provision globally. International collaboration could accelerate delivery of research for example, sharing knowledge on administrative data linked across education, health and other sectors to enable parallel studies across diverse needs and contexts relevant to SEND provision. Surveys, cohort studies, and RCTs of SEND provision, or targeted components, in education or healthcare, could be conducted and linked into administrative data. Such linkages would minimise costs of data collection, and if conducted across jurisdictions, could improve comparability and give insights about differing impacts according to context. Sharing of mixed methods approaches would improve understanding of services across jurisdictions.

International research collaboration is needed to build on the findings from the HOPE study through wider integration of natural experiment, randomised and mixed methods studies to improve the effectiveness of SEND provision. However, the challenges facing the HOPE study, are echoed by other population-based, service interventions, such as early home visiting for first-time, teenage mothers and perinatal mental health hubs [86, 87]. The recent framework on use of natural experimental designs [32], needs to be extended to consider how policy makers, funders, and researchers can introduce and document changes in policy and practice and efficiently enhance administrative data to enable robust evaluation of education, health and social interventions in populations.

Acknowledgements

Members of the HOPE study team include: Ruth Gilbert (PI), Katie Harron, Bianca L De Stavola, Lorraine Dearden, Tamsin Ford (senior work package leads), Kate Lewis, Vincent Nguyen, Ania Zylbersztejn, Jennifer Saxton, Jacob Matthews, William Farr (leading roles in the 4 work packages), Ayana Cant, Laura Gimeno, Hayley Gains, Isaac Winterburn, Ariadna Albajara Saenz, Andrea Aparicio Castro, Julia Shumway, Lucy Karwatowska, Ananya Khera, Nicolas Libuy, Louise Macaulay (contributing researchers), Matthew Lilliman (programme manager), Kate Boddy (public engagement coordinator), Stuart Logan, Jugnoo Rahi, Kristine Black-Hawkins, Johnny Downs (co-investigators).

We are grateful to the HOPE study Advisory Group: Chris Bonell (chair, professor of health and sociology, London School of Hygiene and Tropical Medicine), Kate Evans-Jones, Julia Ogden (public members), Jo Hutchinson (Director of SEND, Education Policy Institute), Karen Horridge (Visiting Professor of Child Development and Disability, University of Sunderland). Thanks to Jo Van Herwegen (UCL IoE) for discussions and comments.

We gratefully acknowledge all children and families whose de-identified data were used in this research. We thank Ruth Blackburn, Milagros Ruiz, Matthew Jay, Antony Stone and Farzan Ramzan for ECHILD Database support.

The ECHILD Database uses data from the Department for Education (DfE). The DfE does not accept responsibility for any inferences or conclusions derived by the authors. This work contains statistical data from ONS which is Crown Copyright. The use of the ONS statistical data in this work does not imply the endorsement of the ONS in relation to the interpretation or analysis of the statistical data. This work uses research datasets which may not exactly reproduce National Statistics aggregates. Evidence from this research contributes to the NIHR Children and Families Policy Research Unit but was not commissioned by the NIHR Policy Research Programme.

Funding

This project is funded by the National Institute for Health Research (NIHR) under its ‘Programme Grants for Applied Research Programme’ (Grant Reference Number NIHR202025, The HOPE Study), with additional support from the NIHR Children and Families Policy Research Unit. ECHILD is supported by ADR UK (Administrative Data Research UK), an Economic and Social Research Council (part of UK Research and Innovation) programme (ES/V000977/1, ES/X003663/1, ES/X000427/1).

Statement of conflicts of interest

Tamsin Ford’s research group receives funding for research methods consultation from Place2Be, a third sector organisation that provides mental health and training to UK schools.

The other authors report no conflicts.

Ethics statement

Existing research ethics approval has been granted for analyses of the ECHILD database version 1 for the purposes set out in the HOPE study (20/EE/0180). Permissions to use linked, de-identified data from HES and the NPD were granted by NHS England (DARS-NIC-381972-Q5F0V-v0.5) and the Department for Education (DR200604.02B). Patient consent was not required to use the de-identified data in this study.

Data availability statement

The ECHILD database is made available for free for approved research based in the UK, via the ONS Secure Research Service. Enquiries to access the ECHILD database can be made by emailing ich.echild@ucl.ac.uk. Researchers will need to be approved and submit a successful application to the ECHILD Data Access Committee and ONS Research Accreditation Panel to access the data, with strict statistical disclosure controls of all outputs of analyses.

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