Identifying service users' experience of the education, health and care plan process: A systematic literature review

Education, Health and Care Plans (EHCPs) were introduced in 2014 to improve provision for children and young people with special educational needs and disabilities (SEND). Some service users have found this change positive, but there is also dissatisfaction among service users with the EHCP process. This was captured in the recent Education Select Committee report, which took evidence from a range of stakeholders, representatives and service users examining the context, support and barriers associated with SEND (House of Commons, 2019). This review identifies and appraises research concerning service users' experience of the EHCP process, to establish key barriers to improving SEND provision. Papers evaluating the experience of children, young people, parents and professionals with EHCPs were included to assess levels of user satisfaction. A total of 25 studies were reviewed in-depth. Five key themes were revealed: lack of integration with health and social care; insufficient knowledge and understanding; involvement of children, young people and parents; increased expectations and demands for professionals; and need for greater parity and clarity. Most service users were dissatisfied with the process and


INTRODUCTION An effective change?
Despite person-centred planning and multi-agency working now being a statutory requirement, research has shown a failure to implement such (House of Commons, 2019), resulting in dissatisfaction with the EHCP process. In a report published by the House of Commons (2019), on the SEND reforms, it was revealed that only a minority of children, young people and parents had positive experiences of being involved in the process. In addition, there was little evidence of the involvement of health and social care services in the process.
However, other factors may be responsible for dissatisfaction among service users. In a study commissioned by the Department for Education, known as the Pathfinder Programme, LAs were tasked with trialling the reforms prior to their implementation (Thom et al., 2015). Families reported experiencing a person-centred process and an increased multi-agency approach, yet still voiced dissatisfaction with the process (Thom et al., 2015). While Cullen and Lindsay (2019) support this, they also highlight the contributing factors of the need for empathy, knowledge and acknowledging wrong.
Statistics published by the Office for National Statistics (ONS) show that 75,951 requests for an EHCP were submitted in 2020, but only 60,097 EHCPs were issued (ONS, 2021b). This highlights that although a sizeable proportion of requests are being made for an initial assessment, many are being declined. Figures from the Ministry of Justice show that appeals against EHCPs have increased by 151.57%, from 3147 in 2014/15 to 7917 in 2019/20 (Ministry of Justice, 2020). One of the most common reasons cited was an initial 'refusal to assess'. 'Refusal to assess' appeals have increased by 276% in the past five years from 603 in 2014/15 to 2270 in 2019/20 (Ministry of Justice, 2020). However, it is not known how many of these cases had a reasonable prospect of winning an appeal but failed to submit one.
Secondly, many appeals were linked to 'contents', which across the various components of need, provision and placement, and under the 2-year pilot, accounted for 4715 appeals (Ministry of Justice, 2020). This suggests that families are not being involved in all aspects of decision-making and that the requirement for a 'person-centred' process is still not being mutually met.

The current study
With an increasing need for EHCPs (numbers have increased by 10% in the last year, rising from 390,100 in January 2020 to 430,697 in January 2021; ONS, 2021b), it is integral that we understand service users' experience of the process. The need to ensure adequate provision for children and young people with additional needs is more crucial than ever, given limited access to education and face-to-face support due to the COVID-19 pandemic (Ofsted, 2020). Previous research has attempted to synthesise literature on EHCPs but has failed to focus on service user experience in a systematic fashion (see Cochrane & Soni, 2020). The current review provides a detailed systematic review of the literature looking at service users' experience of the EHCP process. It highlights areas of dissatisfaction and how such can be targeted. For this review, service users are defined as children, young people, parents and professionals from education, health and social care services.
The review aims first to identify the extent to which the involvement of education, health and social care services in the EHCP process is collaborative; secondly, to identify the extent to which children, young people and their parents are at the centre of the EHCP process; and, finally, to understand whether satisfaction with the EHCP process differs by service user. Figure 1 illustrates the study selection process. The systematic search for literature was carried out on 28 June 2020 using the EBSCOhost research platform. The databases included were Academic Search Complete, PsycInfo and Education Source. Details of the search terms and Boolean operators used are presented in Table 1. Inclusion and exclusion criteria are presented in Table 2. The initial search identified 186 studies.

Search strategy
A further search was also conducted through Google Scholar and the Electronic Theses Online Service (EThOS). In Google Scholar, the advanced search option was selected, and the search terms used were 'experiences OR perspectives AND education health and care plans'. This search identified 482 records. In EThOS, 'education health and care' was entered as a search term, resulting in 20 studies. All records were imported into EndNote to remove duplicates which were also checked for manually (N = 130). This resulted in a total of 558 records.
Initial screening involved reading the title. Where the focus was not clear in the title, the abstract was examined. Papers that did not meet the inclusion criteria were excluded (see Table 2). Studies that included multiple participant groups (i.e., groups in addition to the target groups of children, young people, parents and professionals from education, health and F I G U R E 1 Study selection process social care services), were included, so long as information pertaining to the target groups was distinguishable. This resulted in 533 records being excluded.
The full text of 25 records were read. One further record was excluded as it was a review publication, and six records were excluded as they did not explore service users' experience. Seven additional records were identified a posteriori from reference lists of papers that were read in full (APPGA, 2017;Cullen & Lindsay, 2019;Cullen et al., 2017;Franklin et al., 2018;House of Commons, 2019;NAS, 2015;Scott, 2016). This resulted in 25 studies being included in the review.
The synthesis of literature was structured by the research questions. Given the qualitative nature of the findings being analysed, the principles of Braun and Clarke's (2006) thematic analysis were drawn upon. Selected studies were read in-depth, and details concerning type of service user and relevant findings were extracted. Patterns of findings were examined for conflict, isolation and concurrence. From this, themes were formed.

R ESULTS
All papers included in the review were high quality, as assessed using the Critical Appraisal Skills Programme qualitative checklist (see CASP, 2018). Utilising this checklist permitted a T A B L E 1 Search terms used in Academic Search Complete, PsycInfo and Education Source

Key concept relating to research question Search terms used
Service users "service user*" OR insider OR famil* OR parent* OR carer* OR child* OR "young person*" OR "young individual*" OR "young people*" OR professional* OR SENCO* OR "special educational needs coordinator*" OR "educational psychologist*" OR EP* OR teacher* OR "teaching assistant*" OR "learning support assistant*" OR "school staff*" OR pupil* OR student* Experiences experience* OR perception* OR perspective* OR view* OR opinion* OR voice* OR attitude* OR report* OR review* OR rating OR satisfaction Education, health and care plan process "education health and care plan*" OR "EHC plan*" OR EHCP* OR "education health and care process" OR "EHC process" OR "EHCP process" OR "education health and care needs assessment process" OR "SEND provision" OR "SEND policy" OR "SEND reforms" OR "SEND legislation" OR "SEND support" OR "SEND system" OR "special educational needs and disability code of practice" OR "SEND code of practice 2014" OR "SEND code of practice 2015" OR "SEN provision" OR "SEN policy" OR "SEN reforms" OR "SEN legislation" OR "SEN support" OR "SEN system" OR "Children and Families Act 2014" greater focus towards understanding the validity and value of findings, subsequently proving their quality. An interpretive decision was made on whether a paper was of a high standard while also adhering to the checklist strategy. Literature was identified from a wide range of sources including journal articles, government publications, research reports and doctoral theses. The inclusion of these types of literature was required, as much of the information pertaining to EHCPs is addressed in this type of publication, due to their legal and complex nature. Including gray literature was also crucial to reduce publication bias and increase the review's comprehensiveness (Paez, 2017). Table 3 gives an overview of the studies, including author, publication type, service user and key findings.

Synthesis of findings
The following section provides a narrative synthesis of the key themes identified across the 25 studies.

Lack of integration with health and social care
Evaluation of the 2020/21 school census data (ONS, 2021a) indicates that for most types of SEN that secured an EHCP, there would have been medical input or a medical diagnosis in the identification and management of the need. For example, autism spectrum disorder (ASD), which according to NICE guidelines requires multidisciplinary evaluation and support (NICE, 2017), was the most common type of need (30%) among those with an EHCP. Pupils identified with a primary need of Social, Emotional and Mental Health, and Speech, Language and Communication needs accounted for another 30%. However, even those difficulties which do not immediately present as needing multiservice support (for instance, Specific Learning Difficulties, SpLD), can present with co-morbidities such as motor, language and executive function difficulties (Snowling, 2005). For a proportion of children, an integrative intervention for both proximal and distal forms of difficulty may be needed, with an EHCP required to achieve this. In 2020/21 11,610 children with SpLD met the threshold for having an EHCP compared to 92,567 for ASD (ONS, 2021a). The complex nature of needs for those that meet the threshold, means that many children and young people's needs are unlikely to fall into single service categories. Therefore, collaboration between education, health and social care services is essential to ensure timely and effective support, enabling access to education and progression towards adulthood. Nine studies identified a lack of involvement from health and social care services in the EHCP process, despite the requirement for multi-agency working. This may be due to health and social care workers having a lack of knowledge of the EHCP process (Redwood, 2015) or a lack of understanding of their responsibility in the process (Boesley & Crane, 2018). Further, health and social care workers do not feel competent when addressing healthrelated matters in an educational context (Skipp & Hopwood, 2016), and limited funding exists to resource additional training (House of Commons, 2019).
Where service users did express that health and social care services were involved in the EHCP process, the collaborative nature of this involvement was still disputed (Cochrane, 2016). Service users, particularly special educational needs co-ordinators (SENCOs), highlighted the challenge in bringing together professionals from different services for meetings, due to time pressures (Sales & Vincent, 2018;Tysoe, 2018).
Multi-agency working aims to reduce pressure on families by removing the need to repeat information to different services (Department for Education & Department of Health, 2015), but this is not being realised. Parents often report having to repeat information, concerning Families felt process was being dictated to them by professionals.
Families felt empowered as they were more in control and had the ability to make changes Franklin et al. (2018) Research report Parents, young people, and professionals from education, health and social care services Parents needed to keep relaying same information to professionals from different services.
Minority of young people were involved in their EHCP

Author(s) (year)
Publication type

SENCOs
Parents were more knowledgeable about their rights but lacked understanding of the process.
The need for more procedural support. Difficulty in managing unrealistic parental expectations. Increase in responsibility.
The need for more coherent guidelines and an example EHCP.
Unclear understanding of their role in the process Hellawell ( Thom et al. (2015) Department for Education publication Parents, children and young people Some parents expressed involvement of services was collaborative, some also reported lack of communication between services which resulted in explaining child's needs on multiple occasions.
Lack of involvement impacted children/young people. Majority of families felt listened to and reported experiencing a family-centred process.
Parents felt process was family-centred when professionals who knew the families case were involved Tysoe (2018) Thesis SENCOs Difficult to get professionals from different services together.
Process was a burden due to time consuming paperwork, would not have coped without the administrative support their school offered.
Lack of time resulted in professionals postponing other work or completing work outside of contracted hours | 13 of 24 SERVICE USERS' EXPERIENCE OF EDUCATION, HEALTH, AND CARE PLANS their children's needs, to different professionals (Franklin et al., 2018;Holland & Pell, 2017;Thom et al., 2015). This has led to the needs of children and young people being misunderstood and therefore not met (House of Commons, 2019).
A minority of studies have reported improvement in multi-agency working for some service users (Plender, 2019;Thom et al., 2015), yet this remains the exception. The need for more training resources, more understanding of individual roles and responsibilities, and better communication between services, is repeatedly highlighted. The fact that some settings report improvements, raises questions of where, when and how the EHCP process is being applied from setting to setting. There is widespread agreement from stakeholders that the 2014 Act used to introduce EHCPs, was the right approach but that it failed on implementation (House of Commons, 2019). However, seven years after implementation, patterns of difficulties are persisting. This suggests problems that extend beyond implementation and administration, and into a system of structural features including policy.
In an investigation around the role of policy in supporting children with SEND at risk of exclusion, it was highlighted how for education, co-existing policies can become contrary (Daniels et al., 2019). Daniels et al. (2019) found that policy conflicts had been resolved by privileging accountability over inclusion, resulting in reduced access and increased exclusions for vulnerable and SEND children. This suggests that the structural reform that would guide stakeholder actions, ways of working, and policy priorities needs examination both at the micro and macro level.
A structural reform in how the SEND system operates and is located relative to other policy and accountability systems may go some way to achieving this. The structural reform needs to be one which subsumes health care, social and educational services for children and young people under a single accountability system. Importantly, this requires sufficient power to identify service failure and recognise that each of the services have their own structural features. Accountability would also have the potential to shape the cultural orientation in which stakeholders need to operate. In some respects, the current accountability framework has shaped the environment, resulting in findings such as those reported by Cullen and Lindsay (2019).
Additionally, funding should be ring-fenced. This could allow for more allocation of resources to individual services, or at least reduce the variable and discretionary allocation identified by the current review. A greater clarity of roles, associated expectations and improved communication would also assist. However, structural reform of procedures and processes alone may not achieve this, with change of practice and culture also required (Cullen & Lindsay, 2019).

Insufficient knowledge and understanding
Parents have reported a lack of knowledge and understanding of the EHCP process. Eccleston (2016) revealed that two out of three families reported a lack of understanding of the process, and that they entered the process without any clarity of what to expect, which led to feelings of confusion. Similar findings were revealed by Skipp and Hopwood (2016), where parents expressed feelings of confusion regarding the initial stages of the process. Parents also indicated that they lacked knowledge as they reported wanting more help and information regarding the process (Skipp & Hopwood, 2016). Moreover, parents reported not knowing how to raise a challenge against their child's plan and only the minority had heard of disagreement resolution services (Skipp & Hopwood, 2016). SENCOs have also reported that parents lack knowledge of the procedural aspects of the EHCP process (Boesley & Crane, 2018;Gore, 2016).
In contrast, some professionals have expressed that parents are now more knowledgeable of distinct aspects of the EHCP process (Curran et al., 2017;Gore, 2016;Redwood, 2015). SENCOs felt that parents were more knowledgeable in relation to their rights (Gore, 2016), and educational psychologists (EPs) in Redwood's (2015) study believed parents had a greater understanding of the process. Bentley (2017) found that parents with professional skills had better knowledge of the EHCP process, which led to better outcomes for their children. Moreover, school staff and EPs have expressed believing that the EHCP system favours parents who are wealthy and well educated and that there are parents who lack confidence and are unaware of their rights, making them feel excluded (House of Commons, 2019;Sales & Vincent, 2018). These findings are supported by a study exploring the quality of EHCPs, where differences between LA writing of outcomes were linked to deprivation, with those in more deprived areas having weaker outcomes written (Castro-Kemp et al., 2019).
School staff have also expressed concern with limitations of their own knowledge of the EHCP process. SENCOs voiced a lack of knowledge of the process, expressing feelings of being unprepared and uninformed (Cochrane, 2016). Similar findings were revealed by Gore (2016), with SENCOs expressing the need for more training in procedural aspects of the process. Parents have reported concerns regarding the quality of SEND staff (Adams et al., 2017;Cullen et al., 2017). Cochrane (2016) highlighted a lack of parity of knowledge between professionals, with some staff demonstrating a high degree of knowledge and others not. Professionals and parents have voiced concerns that EHCPs are often written by LA staff who lack sufficient knowledge of SEND and the ability to interpret evidence correctly and write effective plans (Palikara et al., 2018;Skipp & Hopwood, 2016).
Taken together, these findings highlight the need for parents and professionals to be better informed of the EHCP process, including clear expectations of what the process will involve and knowledge of SEND. Better communication between parents and professionals is also needed so both parties are aware of where each other stands in relation to their knowledge of the process and plan itself.

Involvement of children, young people and parents
The extent to which children, young people and their parents are involved in the EHCP process varies. In a report published by the House of Commons (2019), it was revealed that parents were either not involved or that their involvement was problematic. In addition, draft EHCPs often did not consider parents' feedback nor the child's views (House of Commons, 2019). Similar findings were reported by Bentley (2017), where only the minority of parents were involved in co-constructing their child's EHCP. Parents also felt their involvement was reliant upon professionals' qualities, such as how motivated they were to include parents (Bentley, 2017;Sales & Vincent, 2018). Cochrane (2016) suggested that parents were often involved in the EHCP process but that they were heavily guided by professionals, such as SENCOs and EPs. This finding is corroborated by Eccleston (2016), where most families reported that the process was dictated to them by professionals. Families have reported feeling dissatisfied with the EHCP process as a result of not having their views heard by professionals (Adams et al., 2018;Cullen & Lindsay, 2019;NAS, 2015). In contrast to this, some families have reported feeling empowered and better placed to make decisions and changes to proposed EHCPs (Eccleston, 2016;Redwood, 2015;Scott, 2016;Thom et al., 2015), highlighting a huge disparity in service user experience.
Furthermore, the involvement of children and young people in the EHCP process is also inconsistent. The RIP:STARS project was a young person-led, co-produced research project which explored experiences of young people who had varying types of SEND. It also included the views of parents and professionals on the quality of EHCPs. Most parents expressed that their child's involvement in the process was limited. Children also did not know they had an EHCP, or were unfamiliar with its content (Franklin et al., 2018).
The involvement of children and young people in the EHCP process may be limited due to their age or perceived competency (Adams et al., 2018;Redwood, 2015;Sales & Vincent, 2018). Despite all children in Sales and Vincent's (2018) study receiving support in eliciting their views, parents and professionals expressed that the methods used could be more personalised considering the child's age, level of development and communication skills (Sales & Vincent, 2018). However, in some cases methods that were tailored to the child's age and needs failed to have an impact on their ability to articulate their preferences (Adams et al., 2018). This finding is supported by a recent review exploring the methods used for eliciting the voices of young people with communication difficulties, where it was concluded that these methods require improvement (Bloom et al., 2020).
Moreover, another important finding is that professionals having a relationship with the child and their family prior to the process supports their involvement in the process (Redwood, 2015). Similarly, professionals knowing the child's needs as well as the family's case beforehand has also found to support the collaborative involvement (Adams et al., 2018;Thom et al., 2015). Interestingly, in Pearson et al.'s (2015) study, which captured SENCOs' predictions of what impact the SEND reforms would have on their role, it was expressed that the need to have a good relationship with families would require an investment of time, which there would be lacking. However, having a prior relationship presupposes that there is a good working relationship and does not address the fact that if the relationship is challenged then it is difficult to build up. For instance, Cullen and Lindsay (2019) found a substantial sub-group of parents who had issues with school staff attitudes and behaviours which adversely impacted provision and working relationships.
Overall, the increased involvement of children, young people and their parents in the EHCP process has appeared to have been only partially successful. This also falls short of the aspirations expressed in the green paper (Department for Education, 2011). To implement a meaningful person-centred approach, professionals require more knowledge on how to actively involve families in the process. Issues of inequality in the service provided to families through the process could be overcome, and families could feel more empowered. Professionals should also be provided with more time to build a good working relationship with families prior to the process, and the methods used to elicit children's views should be further explored.

Increased expectations and demands for professionals
The increased demands placed on professionals by the EHCP process is a recurring theme across the literature. In a study conducted by Cochrane (2016), parents expected SENCOs to have the most knowledge about the EHCP process, as they were the individuals in contact with the family and external services. Moreover, SENCOs have also reported a difficulty in managing parental expectations as they were often perceived as unrealistic and demanding from within the context they were working in (Boesley & Crane, 2018;Plender, 2019). Similar findings were reported by Gore (2016), where SENCOs also reported needing to remind parents to retain realistic expectations. Similar experiences of dealing with demanding requests by parents were reported by SENCOs in Curran et al.'s (2017) study. However, it can be argued that these expectations in most cases may be only unrealistic in regard to resource pressures, but legally and morally realistic with respect to the individual child.
In addition, professionals have repeatedly expressed how the EHCP process has placed increased demands on them, with reference to the administrative implications. Professionals were concerned with the process being time and resource consuming (Hellawell, 2018;Palikara et al., 2018). This finding is corroborated by Cochrane (2016) and Tysoe (2018), where SENCOs found the EHCP process to be a burden, with time-consuming paperwork. SENCOs also stated how they would have not been able to cope without the administrative support their school offered (Tysoe, 2018). It can be inferred from these accounts of extra burden that schools may have gaps in their 'assess plan do review' cycle and/or additional barriers may have been put in place by LAs to create this additional burden, as this is not what the SEND reforms intend. However, further research is required to explore this.
Furthermore, the increase in paperwork required and the lack of time provided for completion has led to high rates of staff turnover due to sickness and absence (House of Commons, 2019;Palikara et al., 2018;Skipp & Hopwood, 2016). The shortage of staff as well as the limited availability of time has resulted in LAs employing less experienced staff, resulting in poor quality plans and increased delays in the process (House of Commons, 2019;Palikara et al., 2018;Skipp & Hopwood, 2016). Though as noted above, this is also influenced by the level of LA deprivation index (Castro-Kemp et al., 2019). Professionals have reported that the increase in paperwork and lack of time has resulted in them having to postpone other work or complete paperwork outside of their contracted hours (Redwood, 2015;Tysoe, 2018).
Although the administrative demands experienced by professionals is an aspect that frequently occurs across the literature, professionals have also repeatedly reported their increase in responsibility in the EHCP process. In a study conducted by Gore (2016), some SENCOs still had the role of a class teacher but also had to take on all of the other responsibilities required by the SEND reforms, such as managing the involvement of outside services. Moreover, SENCOs reported having to take on the responsibilities of other professionals, such as writing the plan (Gore, 2016). This was also revealed in the Autism and Education in England report where the LA's responsibility of writing EHCPs was passed on to schools (APPGA, 2017).
Professionals, particularly SENCOs, thought that the increased expectations parents have placed on them during the EHCP process were unrealistic and demanding. However, this can be due to the way professionals perceive the world, and so, in the perception of parents these expectations may be realistic. Professionals from all services should be provided with more time and/or more knowledgeable staff should be employed to reduce the demands placed on them. This could result in the process being less challenging and stressful, increasing the capacity to optimise the EHCP process, and potentially improving the quality of plans produced.

Need for greater parity and clarity
A lack of parity within the EHCP process has been expressed by service users, leading to inequality in outcomes and provision. Professionals have highlighted inconsistencies among LAs regarding the procedures followed and paperwork produced, which has resulted in EHCPs containing inconsistent information (Palikara et al., 2018). Likewise, Sales and Vincent (2018) revealed that LAs had different interpretations of how the legislation was to be applied, resulting in different outcomes for children with similar needs (Sales & Vincent, 2018). The issue of inconsistency was not only found between LAs but also within (Sales & Vincent, 2018;Skipp & Hopwood, 2016). Professionals have highlighted a need for more coherent guidelines for the EHCP procedure (Gore, 2016; House of Commons, 2019) and a desire for a model EHCP to provide guidance (Gore, 2016; Redwood, 2015).
A lack of clarity regarding the progress of individual EHCPs was also highlighted. Adams et al. (2018) found that many parents were unclear about the progress of their child's plan even though it had exceeded the 20-week statutory timeframe for issuing a plan. This caused the child and parents to experience a great deal of anxiety and distress (Adams et al., 2018;Cullen & Lindsay, 2019). Similarly, parents expressed feelings of disempowerment due to the lack of clarity about whether paperwork had been completed and submitted (Bentley, 2017).
SENCOs have also reported a lack of clarity regarding refusals, often feeling they were unwarranted (Boesley & Crane, 2018). Cullen et al. (2017) found that refusals could be reduced if LAs clearly communicated what information was required to meet the threshold for issuing an EHCP. However, SENCOs have acknowledged the difficulty of making thresholds transparent as the needs of each child differ greatly (Boesley & Crane, 2018).
Furthermore, the literature has also revealed a lack of clarity regarding individual roles within the EHCP process. In Pearson et al.'s (2015) study, SENCOs expressed feeling uncertain about their role. Intriguingly, this was reported during the shift between Statements of SEN and EHCPs. This may indicate that the role of SENCOs in the former statutory assessment process was clearer. Similar findings were revealed by Gore (2016), where SENCOs revealed having an unclear understanding of what their role entailed in the process. However, this is explained in the CoP (Department for Education & Department of Health, 2015), suggesting that SENCOs could require more support in accessing and understanding this information.
Moreover, the roles of different services are unclear as Skipp and Hopwood (2016) found that parents were confused about who was responsible for acting when needed. Similarly, the House of Commons (2019) reported a lack of clarity about responsibilities as it was found that some schools were paying for health needs to be met.
Overall, a lack of parity within the EHCP process has impacted on children and young people's needs being met, and this is within the context of regional variability in educational outcomes. Professionals should be provided with clearer standardised guidelines that are independent of LA information, and service users should be given greater transparency about the progress of their plan as well as refusals. For instance, the threshold for a statutory assessment is relatively low-it is only that a child may need provision supported by the LA not that they will need it. Moreover, clearer roles for individual professionals and whole services should be established.

DISCUSSION
This review has synthesised existing literature concerning service users' experience of the EHCP process. It has identified limitations in the former statementing process, points of conflict within the EHCP process, and highlighted the needs of children and families involved in the process. Five key themes of areas of tension were identified across the literature; lack of integration with health and social care, insufficient knowledge and understanding, involvement of children, young people and parents, increased expectations and demands for professionals, and need for greater parity and clarity.
The first objective of this review was to identify whether involvement of education, health and social care services in the EHCP process is collaborative, as for many children and parents this underpins the effectiveness of the process. Although some studies reported the successful collaborative involvement of these services (Plender, 2019;Thom et al., 2015), most of the literature highlighted the lack of involvement or collaboration from health and social care services. Though concerns regarding the collaborative involvement of services were only explicitly stated by one study (Cochrane, 2016), multiple studies revealed that service users felt frustrated with the lack of communication between services (Franklin et al., 2018;Holland & Pell, 2017;Thom et al., 2015). This may be due to time pressures, habitual work practice or professionals not having a depth of appreciation of their role and contribution in the process, nor the process itself. It is also the case that the funding, cultures and priorities of services may differ, generating additional barriers.
The second objective of this review was to identify the extent to which children, young people and their parents are at the centre of the EHCP process. Although some parents were involved in early stages of the EHCP, their views were often not included in the final version, or they felt the process was being dictated to them by professionals (Bentley, 2017;Eccleston, 2016;House of Commons, 2019). This both undermines the centrality of the child/young person's and family's voice in the process but also in part contradicts the CoP whereby LAs are legally obliged to include the views of the child or young person and their parents in section A and their views should inform the rest of the plan (Department for Education & Department of Health, 2015). Although parents may be physically present, from the review of evidence considered, including the parliamentary enquiry, there is a marked risk that they are not being actively involved as equal partners and are therefore not part of the centre of the process. The involvement of children and young people in the EHCP process is also limited due to age or perceived competency. Strategies used to elicit children's views should be improved by making them more personalised (Sales & Vincent, 2018), yet this may still be insufficient to cause impact (Adams et al., 2018). Eliciting the voice of the child needs to be further explored to ensure that children's perspectives are at the centre of the process and that useful and meaningful work is done with their voice. Children have limited power to effect autonomy and an even greater limitation is placed upon those outside typical developmental arcs, with greater potential negative consequences. So, their voice is not preferential but central to an effective longer-term outcome. This point was explored by Hartas (2011) in a study of disaffected youth who noted that the best course of action should be defined by both parties.
The final objective of this review was to understand whether satisfaction with the EHCP process differs by service user. This review revealed that overall service users had similar views regarding satisfaction with the EHCP process. Both parents (Franklin et al., 2018;Holland & Pell, 2017;Thom et al., 2015) and professionals (Cochrane, 2016) reported feeling uninformed and unsupported through the process and expressed concerns regarding the lack of involvement and collaboration from health and social care services in the process. Professionals spoke of the administrative implications and increased responsibility they felt the EHCP process had caused (APPGA, 2017;Gore, 2016;House of Commons, 2019;Palikara et al., 2018;Pearson et al., 2015;Skipp & Hopwood, 2016). Additionally, both parents and professionals reported the lack of clarity within the EHCP process. This latter finding is surprising, given the remarkable level of clarity including specified timetables in the CoP regarding how the process should be run and managed by the different contributors (Department for Education & Department of Health, 2015, section 9). Professionals were particularly dissatisfied with the lack of standardisation across LAs regarding the procedural aspects of the process (Palikara et al., 2018;Sales & Vincent, 2018), as well as the lack of clarity in their roles (Gore, 2016;Pearson et al., 2015). Parents were dissatisfied with the lack of clarity regarding the progress of their child's plan (Adams et al., 2018;Bentley, 2017). Taken together, these findings reveal that satisfaction with the EHCP process does not differ by service user grouping.

Limitations of the current review
It is important to consider the limitations of the current review. For the search conducted through Google Scholar and EThOS, only a limited number of search terms could be used to generate results, which may have resulted in bias. Terms deemed most appropriate were selected, however, and all efforts were made where possible to reduce inclusion bias.
The majority of literature included focused on the experience of SENCOs, rather than other professional groups, which limits the possible conclusions drawn by the review. However, this is a general limitation of the body of literature addressing service users' experience of the EHCP process. More research is therefore needed exploring the experience of professionals from health and social care services. The only service user not reflected in the review was LA staff, as there is limited work examining their role and experience in the process. It is important to explore their experience as they have the statutory responsibility and power to shape the process and its outcomes.
Due to discrepancies in procedure across LAs, it can be argued that the comparison of service users' experience from different LAs is limited. The work by Castro-Kemp et al. (2019) is not qualitative in nature and so did not form part of the initial review. However, it does illustrate a lack of parity in terms of the quality of EHCPs. LAs' variability on this measure was linked to deprivation indicators and the form of educational setting. The lack of geographical uniformity as a background in the real-life implementation of an EHCP means that general findings would benefit from including greater contextual analysis. Finally, research has demonstrated that procedural discrepancies are also present within LAs. Again, this is surprising as LAs as entities are built upon policy and procedure as a fundamental aspect of how they do their work. The variability does mean that individual differences regarding service users' experience cannot be discounted and should be recognised.

Implications for practice
The EHCP process begins with the initial request for assessment and through successive stages of gathering information leads to the issue of draft and finalised versions. It was anticipated through the green paper (Department for Education, 2011) that through co-production and multi-agency working many of the points of disagreement and dissatisfaction that characterised the previous regime underpinning Statements of SEN would be resolved, and that structural inequalities could be addressed. The reduction in conflict and dissatisfaction was an important feature of the final legislative outcome of the Children and Families Act (2014) and was supported by the latest version of the CoP (Department for Education & Department of Health, 2015). The data from the tribunals service indicates that those aspirations have not been met for a significant group of families. However, the data only captures those who have followed through the process. There are no readily available figures for those who remain dissatisfied but are not able to engage in disagreement resolution services. As such, this review shines light on an important and hidden area, one that individual practitioners and policy leaders need to be aware of and address.
This review highlights several ways in which the EHCP process can be improved. In common with other inquires, more funding or allocation of resources is required for health and social care services to meet obligations within this framework (Boesley & Crane, 2018;House of Commons, 2019;Redwood, 2015;Skipp & Hopwood, 2016). However, funding alone is insufficient, as funding was provided by the government at the legal transition from Statements of SEN to EHCPs but the lack of ring-fencing meant that the transition was not optimised or seemingly prioritised, as the Education Select Committee noted: 'However, decisions by the Department for Education to allow local authorities to spend their implementation grant with little or no oversight or safeguards was at best naïve, if not irresponsible' (House of Commons, 2019, p. 11, point 19). As such, funding should be ring-fenced to allow for more allocation of resources to individual services that are child focused and consistent with the legal framework of the Children and Families Act (2014). Limited collaboration between services may also be due to a lack of recognition of the benefit of collaboration between the services themselves and the child and parents, as demonstrated by the lack of knowledge professionals have on the process and their role (Boesley & Crane, 2018;Redwood, 2015;Skipp & Hopwood, 2016). Cullen and Lindsay (2019) not only made recommendations of additional funding, but also suggested a culture change of respect, empathy and competence, which could be applied rapidly with goodwill. Therefore, a culture of professionals valuing each other's, and parents' input would provide a welcome change.
Additional training for professionals is needed on how to actively involve parents and children in the EHCP process in a meaningful way (Cochrane, 2016;Eccleston, 2016). This could also address the small but significant number of accounts in which parents find it difficult to accept the nature of their child's needs. One study that captures this resistance is by Bull (2003) where the use of parent support networks for those with children with SpLD were explored and it was found that some parents were resistant to acknowledging their child's difficulties. Although this is an area that requires further investigation, it can be another barrier to navigating the EHCP process and securing effective provision.
Professionals also require more training in terms of the procedural and conceptual aspects of what a legal process is, as parents felt they lacked knowledge and professionals themselves reported feeling unsupported (Adams et al., 2017;Cochrane, 2016;Cullen et al., 2017;Gore, 2016). Parents require greater support and access to knowledge to enable informed and representative contributions (Eccleston, 2016;Skipp & Hopwood, 2016). So far it has been small charities such as SOS!SEN (2021), IPSEA (2021) and Coram (2021), with other individuals doing voluntary work, who have taken it upon themselves to try and enable accessibility to the law for parents, but as a resource they are limited. Greater support for parents could in part reduce the demands put on professionals during the EHCP process and make provision for parent partnership and dissemination of information through the local offer as well as mediation.
There is a need for nationally standardised guidelines to reduce discrepancies across and within LAs (Gore, 2016; House of Commons, 2019; Palikara et al., 2018;Sales & Vincent, 2018;Skipp & Hopwood, 2016). More specifically, a template EHCP for professionals, which also lays out the legal framework, is required (Gore, 2016;Redwood, 2015). Greater clarity is also essential for the responsibilities of individual professionals and service groups within the EHCP process (Gore, 2016;Pearson et al., 2015). A critical issue is the mechanisms and level of redress and repair for parents who have experiences of failure, by the LA or school, of complying with the CoP, including statutory timeframes within the EHCP process, and inadequate, failed or even non-provision of access to education. The current system for remediation has many gaps in its coverage and does not match the costs of meeting need and repairing damage sustained in a timely manner (House of Commons, 2019), thus conferring an advantage to non-compliance. Despite this observation, the Local Government and Social Care Ombudsman (LGSC) was reluctant in their evidence for the Education Select Committee report to seek penalties against LAs above a nominal level (House of Commons, 2019). In contrast, parent advocates disagreed with this and felt that financial penalties would be effective (House of Commons, 2019). It would now seem to be essential for the professional and administrative framework to have mechanisms to hold individuals and services accountable, effectively with respect to forms of service failure, to avoid the potential unintentional rewarding of poor practice. This latter point of problems around accountability was highlighted by the Education Select Committee, with evidence from the LGSC Ombudsman and others highlighting that significant gaps in accountability frameworks had occurred (House of Commons, 2019, p. 41).

CONCLUSIONS
The original green paper (Department for Education, 2011) set out to address three aspects, empowering those who had been marginalised in the original 1996 Act and 2001 CoP (Gillie, 2012). Those elements were: to ensure tailored provision for children and young people required to meet their needs, reduction of the adversarial climate around securing provision, and that the community of SEND service users who have been traditionally disempowered were enabled, and children, along with their parents, are involved in all aspects of decision-making.
This review highlights that those aspirations have not consistently been met, and that changes seemed to have entrenched the difficulties originally described. The current review has considered a range of evidence which revealed that most service users are dissatisfied with the EHCP process. Evidence of successful multi-agency working, which were deemed central to good outcomes in the green paper, and reflected in the legislation, are limited, with health and social care services lacking in knowledge, and time pressures impacting professionals from different services meeting. It is worth highlighting that there has been some partial recognition of this difficulty with the tribunals service running a 2-year pilot starting in 2018 where they could make non-binding decisions on health and social care within the context of an appeal on educational matters (HM Courts & Tribunals Service, 2021). Parents have availed themselves of this service. This also provides some limited evidence of how mechanisms for accountability do have influence.
Both parents and professionals report a lack of understanding of the process, with clear expectations of what the process will involve and relevant knowledge of SEND needed. The meaningful involvement of children, young people and parents is also limited, with children's age or perceived competency limiting this. Professionals report increased demands on their time, with greater responsibility, and what they perceive as unrealistic parental expectations within the context of their setting and service limitations. However, as has been pointed out earlier, this perception by professionals may be a misreading of both what the law and reasonable parents have fair expectations of; with respect to securing good outcomes and equitable access to education for their child. The need for greater clarity within the process is also reported, particularly regarding how the process is conducted and the roles of services in supporting the child.
At an individual level it is always open to professionals to up-skill and become an informed agent of empowerment for the child. However, what the review has highlighted is that while individual action is helpful on a case-by-case basis, there are also structural features that act as barriers, not least is the unresolved problem of conflicts of policy. There is an emphasis on the need for greater funding, time spent and increased knowledge of the process, but the provision of funding without cultural change and accountability has already been demonstrated through the Education Select Committee evidence to be wasteful of resources and harmful to children and for those involved. It is therefore incumbent on those who operate funding purse strings to ensure the aspirations of Parliament with respect to children and families are being addressed.
Although the current review looked at professionals as a whole, future research should explore whether views differ between professional groups. However, further research is first needed focusing on individual professional groups, as the majority of literature is focused on the experience of SENCOs. The lessons from this review have potential to inform wider aspects of any levelling-up agenda.

C O N F L I C T O F I N T E R E S T
No conflict of interest.

E T H I C A L A P P R O VA L
No ethical issues raised.

PAT I E N T C O N S E N T S TAT E M E N T
No person(s) involved in this study.

P E R M I S S I O N T O R E P R O D U C E M AT E R I A L F R O M O T H E R S O U R C E S
Material cited is under fair access and use has been credited.

D ATA AVA I L A B I L I T Y S TAT E M E N T
Data sharing is not applicable to this article as no new data were created or analysed in this study.