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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
Part 1 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 NHS Scotland 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.
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