Scottish Government

A Scottish Executive Review of Speech and Language Therapy, Physiotherapy and Occupational Therapy for Children and Speech and Language Therapy for Adults with Learning Disabilities and Autistic Spectrum Disorder - Summary

This document is also available in pdf format (1mb)

contents

Foreword
Executive Summary
Recommendations

Foreword

We are very pleased to announce the publication of this report.

We are grateful to the members of the review working group and the consultancy team from Queen Margaret University College who conducted the research, for producing this important document.

Many of the report's recommendations on children's services build on those contained in recent reports such as For Scotland's Children, which highlights the importance of integrated working across education, health and social work, and promotes effective joint working across agencies. This is consistent with the Executive's commitment to supporting an inclusive approach to education and to developing the New Community School approach to joint working. Community Care: a Joint Future also emphasises the importance of joint working with the older population relevant to the part of the review that looked at adults.

The report highlights issues of concern to professionals in health, education and social care, as well as to parents and to adults with learning difficulties. Our health White Paper, Partnership for Care, has since clarified the mechanisms for joint decisions on community care - involving NHS Boards and local authorities as partners at the heart of integrated local care through new Community Health Partnerships. Working in partnership with these mechanisms, other agencies and bodies like the new National Workforce Committee, emerging regional structures and NHS Education for Scotland will help determine supply of, and demand for, therapists, workforce planning, management and organisation of services and funding. We believe that many of these concerns are being addressed in the substantial progress already made through the national action plan for the Allied Health Professions (AHPs), Building on Success - Future Directions - since its publication almost exactly a year ago.

Future Directions stresses the unique nature of each of the nine constituent professions within the AHP community, which includes Speech and Language Therapists, Physiotherapists and Occupational Therapists - but it also addresses common issues affecting all practitioners regardless of speciality. We are providing resources aimed at improving recruitment and retention, and we are providing additional AHP student places. In addition, a number of key groups have been set up to work with existing AHP groups, NHSScotland, the higher education sector and the people of Scotland to ensure progress is made across the board. Specifically, a Ministerial Implementation Group (MIG) will be overseeing the implementation of Future Directions. Five short-life working groups covering Research and Development, Clinical Placements, Staff Governance, Careers Information, and Recruitment and Retention will report to the MIG.

Of course, this report is not just about services for children. In May 2000 the Learning Disabilities Review, The same as you? reported that adults with learning disabilities requiring speech and language therapy were finding difficulty in accessing services. We therefore agreed to extend the scope of the review to include adult speech and language therapy services. And we expect our main recommendations on these - access to services; involvement of adults with learning disabilities and their families in planning, delivery and evaluation of services - to be taken forward through the Partnership in Practice agreements being developed between local authorities and NHSScotland.

Overall, the report sets out 28 recommendations. Clear, specific actions will be required to ensure these are addressed, within the context set out in this foreword. To ensure publication of the report within a reasonable timescale, a selection of views were sought reflecting the diversity of these services in Scotland. But there is a need to be properly inclusive so that all interests are fully represented. So, in publishing this report, we welcome comments from recipients by Friday, 31 October 2003. Thereafter, we will publish a full response to the report.

August 2003

The contact for recipients of this Review who wish to comment is

Miss Ella Macneil
Scottish Executive Health Department
GE.19
St Andrew's House
Regent Road
Edinburgh EH1 3DG
Emailella.macneil@scotland.gsi.gov.uk
Tel: 0131-244-2854.

Executive Summary

Introduction

1. This report outlines the work of the Review of Speech and Language Therapy, Occupational Therapy and Physiotherapy for children and Speech and Language Therapy for adults with learning disabilities in Scotland, commissioned by the Scottish Executive in 2002.

2. The review was carried out by researchers from Queen Margaret University College, guided by a steering group made up of representatives from the Scottish Executive Education Department and the Scottish Executive Health Department as well as advisors from a number of stakeholder groups.

3. The terms of reference of the review were:

• An examination of the supply of Speech and Language Therapists, Physiotherapists and Occupational Therapists to meet the needs of children requiring these therapies

• An examination of the management and organisation of Speech and Language Therapists, Physiotherapists and Occupational Therapists for children with special educational needs

• An examination of how the current funding mechanisms for Speech and Language Therapy services for children operate and how these might be improved

• Consideration of whether the funding mechanisms for Speech and Language Therapy, Physiotherapy and Occupational Therapy services for children should be aligned

• An examination of the supply, management and organisation of Speech and Language Therapy services for adults with learning disabilities.

4. The supply, management and organisation of Speech and Language Therapy services for adults with autistic spectrum disorder who do not have a learning disability was also included in the remit.

5. This report does not cover analysis of the roles of therapists of the same profession working in different organisations or those between different professions.

Background to the report

6. The report provides a background to recent initiatives which led to the Scottish Executive commissioning this report. These include research on children's needs by the Joseph Rowntree Foundation and recommendations from the Riddell Advisory Committee on Severe Low Incidence Disability and from the White Paper on learning disability The Same as you?. It outlines ways in which children requiring therapy, or related interventions, and adults with learning disability and/or autistic spectrum disorder (ASD) are defined. It then summarises the legislative framework within which the therapy needs of children and adults with learning disabilities and/or ASD are identified and met. The development and impact of the current funding mechanisms for Speech and Language Therapy for children who have Records of Needs is then discussed.

7. Theoretical policy and practice frameworks which are of relevance to the review are explored. Attention is drawn to the philosophical concept of inclusive education for children with disabilities and the way this is being put into practice through legislation and policy guidelines. The theme of inclusion is continued in addressing the implementation of The Same as you? agenda for people with learning disabilities. Finally the current status of joint funding initiatives designed to facilitate seamless provision of services by local authorities, the NHS, the voluntary sector and other interested bodies is considered.

Methodology

8. The investigation was undertaken as two separate, but inter-linked studies, which were carried out in parallel. One study examined Speech and Language Therapy (SLT), Occupational Therapy (OT), and Physiotherapy (PT) input to services for children and the second study examined Speech and Language Therapy input to services for adults with learning disabilities and/or ASD.

9. In each study, information was gathered in two phases. For children's services, phase one involved a series of questionnaires for managers of NHS and Local Authority services as well as voluntary organisations. Questionnaires were also sent to Scottish universities providing pre-registration training for Occupational Therapists, Physiotherapists and Speech and Language Therapists. The review received almost 100% return rate from NHS services. A return rate of 72%, representing less than 50% of the population) was received from Local Authorities. Two NHS Board areas were involved in phase two. Here, group interviews were held with purchasers of Speech and Language Therapy from Local Authority education departments and individual interviews were carried out with managers of selected children's services in which Speech and Language Therapy, Occupational Therapy and Physiotherapy are available.

10. For adults' services, in phase one a questionnaire was sent to NHS managers of Speech and Language Therapy for people with learning disabilities. Information was gathered by telephone from voluntary organisations. Data relating to adults with ASD were also collected through learning disability services. Questionnaires were returned by services from 13 of the 15 NHS Board areas (87%). In phase two, interviews were conducted with a manager of a Speech and Language Therapy service in each of the two NHS Board areas noted above.

11. Data analysis involved quantitative measures for numerical data and a qualitative framework approach to analyse data from interviews and focus groups. Data relating specifically to supply, demand, funding, management and organisational issues were identified.

SERVICES FOR CHILDREN

Supply

12. The data collected through the surveys confirm the Riddell Committee's concern that there are shortages of NHS therapists working with children and unacceptable waiting times for some children.

13. There were varied interpretations of terms such as 'caseload' and different approaches to managing referrals, making it difficult to quantify supply and demand reliably. However, it is clear that there are too few experienced therapists, recruitment difficulties in rural areas and growing numbers of referrals.

14. There are a number of key factors influencing the supply of NHS therapists. First, although actual numbers of vacant posts are low, there are high percentage vacancy rates for therapists in children's services and many of these persist for three months or more. This is particularly an issue in remote and rural areas. Secondly, there is currently too small a pool of therapists to draw upon to fill posts which require some experience and expertise. In addition, there are too few opportunities for therapists to develop paediatric experience. Thirdly, there is evidence that skill mix is being affected by the pressure on services to meet demand. Fourthly, there appears to be inadequate IT infrastructures and administrative support for therapists.

15. The majority of therapists working in specialist paediatric services are female and under 40. Temporary absences in particular for maternity leave are not well covered at the present time. Managers would like to have contingency funds to cover maternity and sick leave, supernumerary staff to cover fluctuations in staffing, and automatic or emergency approval of funding to cover maternity leave. The introduction of family friendly policies is having a positive influence on recruitment and retention. However, this creates new challenges such as maintaining continuity within the service and good communication when so many employees work part time.

Demand

16. Most children are offered an initial assessment appointment within six to eight weeks, however, some children are waiting for 32 weeks or longer to receive an initial appointment from an NHS therapist. Children in rural areas can experience long delays for all disciplines and children who speak minority languages appear to be waiting longer than other children to receive SLT. There are inequities of NHS therapies both within and between NHS Board areas. In addition, some children are waiting for long periods to see an OT working in a Local Authority social work service, particularly in rural areas.

Workforce

17. Within the NHS long waiting lists and increased demand from children with ASD and children with complex health needs, as identified in this review, would indicate that children's services require an increase in numbers of therapists - or alternative methods of practice. Just as the factors affecting supply and demand are multiple, so the strategies needed to tackle the problems will be multiple. Increasing posts alone will not necessarily ease pressure. A long-term strategy for workforce planning based on a comprehensive analysis of multiple factors is needed.

18. The key workforce issue which must be addressed is the need to maintain and increase the pool of therapists who are suitably trained and experienced to meet the needs of children in an inclusive setting.

Funding

19. Most NHS therapy posts are funded from the mainstream health budget. The exception is SLT which receives a significant amount of funding from Education departments. NHS therapists from each of the three professions expressed concerns about the ability of services to meet increasing demand without additional resources, regardless of the source of this funding.

20. The additional funding received by SLT through Education departments was welcomed by managers. The main benefits of the funding identified by SLT managers have been increased staffing and a greater dialogue between NHS therapists and Education services. However, the review has identified a number of difficulties relating to the funding mechanism, including the unhypothecated nature of the funding, the protracted amount of time and energy that is spent on negotiating contracts, erosion of SLT provision and a problematic link between the funding and the Record of Needs system. It is clear that the current mechanism of funding SLT through education contracts is problematic and that the mechanism should not be replicated for OT and PT in its current form.

Management and organisation

21. Close co-operation and good communication between the work of Education, Social Work and Health at all levels is essential if holistic services are to become a reality. While there was no consensus on the best way to achieve a joined-up working approach, however, there was agreement that clear lines of accountability are crucial.

22. Equipment and adaptation services, in which therapists play key roles, are particularly fragmented with each agency having different responsibilities and different areas of expertise. There appears to be a number of specific gaps that need to be investigated further and addressed. The current division of responsibility for the purchasing, assessment and maintenance of equipment used by children in schools is unsatisfactory although it is clear that agencies welcome joint initiatives to improve this situation.

23. The report of the Strategy Forum: Equipment and Adaptations explores these issues in more detail. It recommends that partners across all sectors, involved in implementing the agenda for integrated and accessible children's services, should work together with a proposed Implementation Steering Group to establish a lifelong approach to the implementation and development of their strategy.

Recommendations

24. The report makes 21 recommendations on therapy for children. In particular, it is recommended that:

• Local Authorities and NHSScotland should develop integrated approaches to the provision of therapy and other related interventions for children

• a systematic approach to workforce analysis and development is adopted for paediatric therapists and other therapists working with children

• steps be taken to expand the pool of suitably experienced and skilled therapists and clinical support workers

• the structure and skill mix within individual therapy professions should be reviewed to ensure effective and efficient use of resources and ability to meet demand. AHP leaders ⁱ professional bodies, NHS Boards and Local Authorities, where appropriate, should work in partnership in taking this forward

• initiatives should be progressed to tackle recruitment, retention, training, supervision and, in particular, support issues in remote and rural areas

• NHS Boards should take steps to minimise the length of time that children have to wait for therapy

• funding for Speech and Language Therapy to education authorities for provision to pupils with Records of Needs should be integrated with funding for SLT to other children

• strategic planning arrangements are established to ensure the involvement of key stakeholders and effective and efficient delivery of services by therapists.

SPEECH AND LANGUAGE THERAPY FOR ADULTS WITH LEARNING DISABILITIES AND/OR AUTISTIC SPECTRUM DISORDER

Supply and demand

25. The majority of services for adults with learning disabilities and/or autistic spectrum disorder are provided by SLTs employed by the NHS, while a small number of SLTs are employed in the voluntary sector. Learning disability has traditionally been seen as one of the 'Cinderella services'. There are few opportunities for new graduates to gain experience of working with people with learning disabilities early in their career and it has been difficult to recruit to this field, although there are likely to be some interesting developments in services as a result of the implementation of The same as you?

26. There was some variation in the number of state registered Speech and Language Therapists per 100,000 population in the 12 areas for which there is complete data, suggesting some inequities in the level of service available. Vacancy rates overall are low although there are high vacancy percentage rates in a small number of areas. Rates of maternity and sick leave are also low.

27. There does not currently appear to be excessive demands being placed on SLT adult learning disability services as a whole. These findings contradict the findings of the report The same as you? which suggested that adults with learning disabilities found it difficult to access Speech and Language Therapy.

Organisation and management

28. The service for adults with learning disabilities is relatively well defined, but that for adults with ASD but no learning disability, is neither well defined nor identifiable. This may be one reason why so few of this client group are referred to SLT. It may also be the case that adults with ASD but no learning disability do not view themselves as having a 'need' or as having a need that requires health input from the learning disability service. If this client group does have a need that can be met by SLT then the challenge for these services is to be more creative in finding ways to make themselves visible, accessible and acceptable.

Recommendations

29. The report makes seven recommendations for speech and language therapy for adults with learning disability and/or ASD. In particular, it is recommended that:

• NHS Boards should explore why people with learning disabilities and/or ASD experience difficulty in getting a service, when the level of demand on services does not appear to correspond to anticipated levels of need

• NHS Boards should ensure that services in which speech and language therapy is provided encourage and accept appropriate referrals from adults with ASD but without a learning disability

• Opportunities should be created for students and new graduates to experience work in this field

• People with learning disabilities and/or ASD as well as their families are involved in the planning, delivery and evaluation of services.

Conclusion

30. The consultants are grateful to the many respondents to the surveys for giving up their time to contribute to this review and to the steering group for its expertise and advice.

Recommendations

OCCUPATIONAL THERAPY, PHYSIOTHERAPY AND SPEECH AND LANGUAGE THERAPY FOR CHILDREN

1. The working group proposes a number of recommendations relating to issues of strategic planning which take account of recent reports and current Scottish Executive initiatives in education, health and social services. These include For Scotland's Children; Building on Success: Future Directions for the Allied Health Professions in Scotland; and Community Care: A Joint Future.

2. Other recommendations are grouped within the terms of the remit for the review under supply and demand, management and organisation and funding. Others are listed under workforce or other issues.

Strategic planning

a) The Scottish Executive should encourage providers to develop new models of NHS therapy provision in non-traditional and inclusive settings, such as mainstream schools and nurseries and other community settings; and multi-agency training initiatives to support the delivery of therapy to children in inclusive educational settings. [Part 3, paras 6-10; Part 5, paras 124-126; 188-190]

b) Local Authorities and NHSScotland should develop integrated approaches to the provision of therapy and other related interventions for children. These approaches should be planned and resourced within the statutory framework of local planning for children's services. Inter-agency Children's Services Plans should describe assessed levels of need and the provision made to meet these. [Part 3, paras 14-15; Part 5, paras 106-111]

c) NHS and Local Authorities should apply lessons learned from implementation of the Joint Future agenda in community care services, to their implementation of For Scotland's Children, the Executive's initiative on better integrated services for children. [Part 3, paras 14-15]

d) The Scottish Executive Health Department, NHS Boards and Local Authorities should ensure that the national, regional and local structures established through Working for Health involve AHP leaders and that a systematic approach to workforce analysis and development is adopted for NHS paediatric therapy. This should be an integrated approach involving key stakeholders,
e.g. professional bodies, HEIs and NES, and LA partners. [Part 5, paras 144-153]

Supply and demand

e) NHS Boards and Local Authorities should review the structure and skill mix of therapy staff in services to children, to ensure effective and efficient use of resources, ability to meet demand and the provision of training opportunities for junior grades of staff and assistants. [Part 5, paras
22-24;133]

f) The Scottish Executive, the Scottish Higher Education Funding Council, NHS Boards and Local Authorities should, together, take steps to expand the pool of suitably experienced and skilled therapists and clinical support workers. They should take into account opportunities to develop alternative routes into state registration in partnership with the Health Professional Council (HPC), universities, NHS Education for Scotland, Scottish Qualifications Authority and professional bodies. [Part 5, paras 26-29;132; 154-155]

g) NHS Boards should progress initiatives to tackle recruitment, retention, training, supervision and support issues in remote and rural areas through the Remote and Rural Areas Resource Initiative (RARARI) in NHSScotland. [Part 5, paras 30; 131; 138]

h) NHS Boards should take steps to minimise the length of time that children have to wait for therapy required to support their educational needs. [Part 5, 55-57; 139-143]

Management and organisation

i) NHS Boards, Local Authorities and other employers of AHPs, in determining their therapy staffing complements for children's services, should take into account the impact of planned leave, including projected maternity leave, and changing workforce patterns, so that there is continuity and comprehensiveness of service as outlined in Building on Success - Future Directions for the Allied Health Professions in Scotland. In addition, they should use Partnership Implementation Network guidelines to develop and implement flexible employment policies to support the recruitment and retention of staff. [Part 5, paras 8-24; 31-37; 135-136]

j) NHS Boards through AHP leaders should audit the time spent by therapists on non-clinical tasks, such as routine administration, and seek to maximise AHP time on direct service delivery. [Part 5, paras 25; 134]

k) NHS Boards should fully utilise the enabling agreement and other mechanisms which exist to recognise and reward clinical expertise in order to promote job retention in paediatric services. These include developing opportunities for new ways of working and improving clinical care such as 'extended scope practitioners', clinical specialist or AHP consultant posts. [Part 5, paras 37-40; 154-168]

l) NHS Boards and AHP leaders from each therapy profession should ensure that each therapy profession has a clear rationale for caseload management decisions which is developed in consultation with key stakeholders such as parents, education colleagues and, where appropriate, children. [Part 5, paras 60-68]

m) AHP employers and leaders should support the development of multidisciplinary and multi-agency networks to underpin practice development. These should review and share clinical effectiveness information developed by each profession in partnership with families using services. [Part 5, paras 188-190]

Funding

n) Allocation of funding for Speech and Language Therapy to Education Authorities for provision to pupils with Records of Needs should be integrated with funding for SLT to other children. Provision of therapy should be made according to clinical need and be outcome-focused rather than led by diagnosis, label or administrative category. [Part 5, paras 82-85; 176-182]

o) The Scottish Executive should, with Local Authorities and NHSScotland, develop joint resourcing and management for children's services, including the therapy professions' contribution. [Part 5, paras 94-105]

Workforce

p) Competencies required to deliver and manage a high quality children's service should be established by OT and PT leaders in line with similar work in SLT. This should be undertaken in partnership with professional and regulatory bodies, and HEIs, and used to inform the work of NES in developing education and training and continuing professional development. [Part 5,
para 150]

q) NHS Boards and Local Authorities should create opportunities for students and new graduates to gain experience of working with children. In the NHS they should consider arrangements for the payment of clinical supervision allowances, within the timeframe for the implementation of the UK Agenda for Change initiative. [Part 5, para 159]

Other issues

r) NHS Boards, Local Authorities and AHP leaders should develop strategies for involving children, young people and their families in service evaluation and development in line with the 'Involving People' agenda, [Part 5, para 153].

s) NHSScotland commissioners with NHS Boards and SLT leaders should review the current level of bilingual SLT available to families from minority ethnic communities in their area and should take steps to address service gaps. [Part 5, para 58; 140]

t) NHS Boards and Local Authorities should put in place strategic planning arrangements to ensure that effective and efficient joint systems and protocols are developed to meet the equipment and adaptation needs of disabled children. These arrangements should cover assessment, funding, provision, monitoring, maintenance and recycling of equipment. Developments should link with activities under A Joint Future and Education Departments' Accessibility Strategies. [Part 5, paras 186-187; 115-123]

u) As part of local implementation of Accessibility Strategies, Education Authorities, in consultation with NHS Boards and Head Teachers, should agree appropriate accommodation and facilities for the provision of therapy in educational settings. [Part 5, paras 127; 191]

SPEECH AND LANGUAGE THERAPY FOR ADULTS WITH LEARNING DISABILITIES AND/OR AUTISTIC SPECTRUM DISORDERS

Strategic Planning

a) NHS Boards should review access to therapy for adults with learning disabilities and/or ASD, their families and professionals so that their needs can be better met and unmet needs identified. In doing so they should explore why people with learning disabilities and/or ASD experience difficulty in getting a service, when the level of demand on services does not appear to correspond to anticipated levels of need. [Part 6, paras 21; 35]

b) NHS Boards should ensure that services in which SLT is provided encourage and accept appropriate referrals from adults with ASD but without a learning disability. [Part 6, paras
24-27; 37]

c) NHS Boards and Local Authorities should involve adults with learning disabilities and/or ASD and their families in the planning, delivery and evaluation of services. They should also make sure that the communication needs of adults with learning disabilities and/or ASD are taken account of in Partnership in Practice agreements. Local databases of people with learning disabilities should include information about the communication needs of adults with learning disabilities and/or ASD. [Part 6, para 37]

Supply and demand

d) NHS Boards should develop and implement flexible employment policies to support the recruitment and retention of relevant staff. [Part 6, paras 11-14]

Service provision

e) SLT services should review and disseminate information about new developments and innovative practice in therapy for adults with learning disabilities and/or ASD. Particular efforts should be made to provide accessible information to adults with learning disabilities and/or ASD and their families. [Part 6, paras 28-32]

Workforce

f) NHS Boards and other employers in conjunction with HEIs should create opportunities for SLT students and new graduates to gain experience of working with adults with learning disabilities and/or ASD in community settings and in remote and rural areas. [Part 6, para 34]

Research

g) The Scottish Executive should fund comparative research on what models of practice produce good outcomes for adults with learning disabilities and/or ASD. [Part 6, para 40]

Further copies of this publication are available from
The Stationery Office Bookshop
71 Lothian Road
Edinburgh EH3 9AZ
Tel 0870 606 55 66