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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

Appendix B Role of Occupational Therapists, Physiotherapists and Speech and Language Therapists with children and people with learning disabilities and/or autistic spectrum disorder

Role of the Occupational Therapist when working with children

1. Within the NHS Paediatric Occupational Therapists are specialists within their field and are trained to work with children with special needs including those with a physical disability, co-ordination and specific learning difficulties, emotional and/or behavioural difficulties, learning disabilities and acute or chronic illness.

2. They can work in a variety of settings: child development centres, nurseries, schools (mainstream and special schools); at home or in hospitals.

3. They may provide assessment and intervention in the following areas:

4. Within social work services (and housing) Occupational Therapists work with children with special needs living in the community. They specialise in the assessment and management of problems at home, providing assessment, advice and assistance to carers and families and assessing for and arranging provision of, equipment and adaptations within the home and immediate environment. They also play a key role in terms of housing options and in sourcing specialist and alternative housing when required.

5. In addition they provide a specialist assessment service to Children and Families teams within Social Work Services in terms of the management of 'cared for' children who have special needs including within a fostering and/or adoption setting.

6. They accept direct referrals from a wide range of sources for children with physical disabilities, learning difficulties and, increasingly, behavioural problems. They also deal with children with very profound multiple disabilities.

7. Work with children and families will usually, but not exclusively, take place in the home environment. They may also be asked to advise on environmental adaptation of school and residential environments.

Grading of Occupational Therapy Staff

8. Within the NHS paediatric occupational therapists are employed on a range of grades, but predominantly senior 1.

9. The different responsibilities of different grades of staff are dependent largely upon where that therapist works, how they are supported/supervised and a range of competencies within the area of Paediatric Occupational Therapy for example, for clinical skills. A basic grade Occupational Therapist would be able to carry out the occupational therapy process with an appropriate level of guidance and within agreed parameters of practice. A Senior II would be able to practice independently within agreed parameters of practice. A Senior I would be able to select from an extensive range of assessments, implement intervention and reliably predict outcomes.

10. Deciding upon grades of staff may also depend on how the service is delivered for example a hospital-based service may have more flexibility to adopt a wider skill mix in comparison to a community-based (primary care) service in a rural area.

11. Within social work services occupational therapists are employed on local government pay and conditions, as a community occupational therapist or care manager. Although they may work as part of a multidisciplinary social work team, where they are not managed by an occupational therapist they will receive professional support and supervision from a more senior member of the profession.

12. Salary levels between the NHS and social care tend to fluctuate. At the present time these are more favourable to those working in the NHS, although pay and conditions are not the only factors that influence decisions on where to practice.

Role of Occupational Therapy Assistants

13. Within the NHS Paediatric Occupational Therapists increasingly have Occupational Therapy Assistants working alongside them. With the appropriate levels of induction, training and guidance, they can demonstrate sufficient knowledge and competence to implement programmes, particularly in schools, and can contribute to reviewing the child with the Occupational Therapist.

14. Assistants are also used for organising and planning treatment sessions and managing, with supervision, their own time. Assistant posts attract a wide amount of interest from a variety of people with varying skills and knowledge. Most have no formal qualifications relating to working with children but can acquire these as they are in post, if required.

15. Assistants require extensive induction and in-service training programmes which can be run in conjunction with other professions. Employing a broad skill mix, including assistants, depends on there being a sufficient ratio of trained staff to provide adequate training and supervision. Many third-level education facilities offer courses on child development or special educational needs, which would also be of relevance to assistants working in paediatric settings.

16. Although within social work services assistants are employed to work extensively across a range of service areas, the intervention required from an occupational therapist would usually require their specialist expertise, and opportunities to delegate to an assistant may be limited.

17. In Edinburgh and Glasgow HNC course in Occupational Therapy Support are available, usually through a 2-year day release programme. However, securing finance to fund these courses can be difficult.

Role of the Physiotherapist when working with children

18. The Paediatric Physiotherapist is concerned with the assessment, treatment and management of children who have a general developmental delay, disorder of movement, disability or illness which will be improved, controlled or alleviated by physiotherapeutic skills and/or the use of specialised equipment.

19. Paediatric Physiotherapists offer treatment for children with problems, caused by neuro-muscular, musculo-skeletal and cardio-vascular/respiratory conditions. Paediatric Physiotherapy covers most of the multiple pathologies which benefit from physiotherapeutic intervention, e.g. cerebral palsy and developmental delay, progressive neuro-muscular disorders, elective and acute orthopaedics, burns and plastic surgery, haematology and oncology, and a wide range or respiratory conditions including intensive care and neonatal care. The Paediatric Physiotherapist requires specialist paediatric core skills and in addition requires to develop skills particular to the different specialities encountered.

20. The Paediatric Physiotherapist has a key role in helping to facilitate a child's maximum attainment.
An in-depth knowledge of the physical, emotional, behavioural and social variables of child development is essential. The child is seen in the context of the family who has a key role in the team involved with the child and the Paediatric Physiotherapist is required to balance the child's needs and those of the family and offers support and teaching to the families involved in the child's care.

21. Access to education is important for the children and Paediatric Physiotherapists must be able to participate in this process and distinguish between a child's physiotherapy needs for home and the physiotherapeutic intervention required to enable a child to gain maximum benefit from education. The Paediatric Physiotherapist rarely works in isolation and must be able to work together with other professionals as part of a multidisciplinary and multiagency team. All children referred for physiotherapy are assessed to identify problems which may indicate that physiotherapy is appropriate. Following assessment a treatment plan is drawn up in conjunction with parents and other carers (this may include school staff). This treatment plan should contain goals, which are agreed and understood by the family and other carers. Individual treatment by the physiotherapist is a very small part of a physiotherapy programme and the management plan should reflect the need to incorporate the skills into normal daily activities carried out by carers in all environments.

22. Paediatric Physiotherapists work in a variety of environments including hospitals, clinics, children's homes, nurseries, children's centres and schools. Equipment may be a fundamental part of a child's treatment and management programme. The Paediatric Physiotherapist ensures that any equipment supplied is suitable for the child and the purpose for which it has been supplied. The Paediatric Physiotherapist has a role as an adviser and educator to families, other carers and education staff who are involved in the supply and use of specialised equipment.

23. Physiotherapy can be reactive and proactive. The Paediatric Physiotherapist may be required to respond to an emergency or urgent situation within the hospital setting, the treatment duration being relatively short or there may be referred children who are likely to require treatment over many months or years. Paediatric physiotherapy is offered for as long as the child is at school at which point they are transferred to adult services irrespective of age.

Grading of Physiotherapy Staff

24. The majority of paediatric services employ Senior II Physiotherapists upwards. It is considered preferable that Senior II staff should have 1-2 years in the general adult setting in order to consolidate their core skills.

25. Some Senior II staff join the service with little or no paediatric experience and may be taken on in a training role. In multi-speciality settings they will have the opportunity to gain experience on a rotational basis. Senior II staff are responsible for the management of their own caseload but should have an identified Senior 1 Physiotherapist who provides clinical supervision and training.

26. Senior I physiotherapists have paediatric experience and skills in paediatrics or a paediatric speciality. They are responsible for managing their own caseloads, monitoring other staff's caseloads, taking responsibility for supervising staff within their area of work and teaching and training other physiotherapy staff, students and other health professionals.

27. They offer expert physiotherapy opinion and advice to other health care professionals and families, lecturing in their field of expertise. They are responsible for facilitating the clinical effectiveness agenda within their area of work and undertake managerial support roles.

28. Senior I staff may also undertake a team leader role although in some areas these posts are graded as Superintendent III - this needs to be addressed. This can cause a significant increase in responsibility as their role is to co-ordinate a team within an area, e.g. Acute services, Community services, Special schools or on a geographical or specialty basis.

29. General comment: There is a clear sliding scale of skills, expertise and expected responsibilities from a Senior II upwards. It is advisable that staff working single-handed or without supervision should be in Senior I posts and have the necessary skills to support families and other carers. Equally it is important that there are posts for Senior II staff for succession planning.

Role of Physiotherapy Clinical Support Workers

30. Physiotherapists are ultimately responsible for the physiotherapeutic management of their patients and must take control and responsibility for the proper and appropriate use of assistance within physiotherapy.

31. Physiotherapists will delegate tasks to Physiotherapy clinical support workers depending on their assessed level of competence and evidence of ongoing training. Having achieved an acceptable level of competence Physiotherapy Assistants and Technical Instructors will continue to deliver treatment management programmes specifically detailed and taught by the Physiotherapist responsible for that individual child and family, e.g. repetitive developmental programmes, positioning, respiratory treatment and the provision of equipment. They work closely with the named Physiotherapist and only change treatment programmes under close supervision. They also work in and around hydrotherapy pools and with groups of patients.

32. There are four career bands - Physiotherapy Assistant and Technical Instructor I, 2 and 3. Presently Physiotherapy Assistants require no training/qualifications when they apply or are appointed and this is provided in-house but there is no standard approach.

Role of the Speech and Language Therapist when working with children

33. The ethos of SLT is that it is the right of every child to be able to communicate to the best of their ability. The aims/principles of service delivery are to promote the child's communication and/or eating and drinking skills in order that s/he may achieve optimally:

• in satisfying the child's/other's needs and desires

• in exchanging information

• in using language creatively

• in initiating and maintaining social interaction

• in learning and in participating in education.

34. Children can access SLT from many different routes. Most services operate an open referral system. Following referral, the child will receive a period of assessment. Assessment should lead to a differential diagnosis of the child's difficulties and form the basis for any plan of intervention. Intervention may be carried out by the therapist directly or indirectly, it may also be facilitated by the therapist and carried out by, e.g. a parent. Intervention is the joint responsibility of therapist, child, parent and/or other professionals.

35. Where intervention is carried out by a multi-disciplinary team the programme will be drawn up in conjunction with the other team members and have clearly defined aims and objectives for therapy.

36. Intervention with a child at school or nursery should be planned jointly with education staff to fit in with the child's overall educational programme and address educational issues, including access to the curriculum. Intervention should also include the provision of in-service training to others involved with the child.

37. The child may be discharged from therapy at any point following referral, subsequent to a case management decision to do so. Normally the decision to discharge will be taken by the therapist responsible for the child's care in the light of progress and/or change in performance. Discharge will always be discussed with parent and with child where appropriate.

38. Children can access therapy from birth, e.g. cleft palate, eating/drinking difficulties, Down's syndrome and at any time throughout their school life. The nature of intervention will change with the child's changing needs.

39. Therapy is provided for children who have a difficulty with communication and/or eating and drinking. The list includes:

• developmental speech and language disorders

• dysfluency

• developmental dysthnia

• dyspraxia

• eating and drinking difficulties

• communication impairment relating to an aetiology

• learning difficulty

• physical impairment

• visual impairment

• hearing impairment

• mental health

• autistic spectrum disorder

• traumatic brain injury.

40. Children may be seen in their home, at a clinic, nursery, child development centre or school.

41. Within any group of children, there will exist a continuum of need and an optimum time to deliver therapy. Therapists will use the evidence base to ensure they deliver therapy when it can be most effective.

Grading of Speech and Language Therapy Staff

Role of Speech and Language Therapy Clinical Support Workers

42. SLT clinical support workers work under the direction of a qualified clinician. Clinical support workers are routinely engaged in a wide range of clinical settings with a range of client groups, activities and duties. They carry out individual and group therapy, contribute to assessments, prepare materials and assist in case history taking. As with all members of staff they are required to carry out administrative tasks such as photocopying and arranging clinics.

43. Clinical support workers are not required to complete a qualification before they take up employment. However, they may bring a variety of existing skills or qualifications which can be of direct benefit to the service, e.g. nursery nurse qualifications. Training varies form health and safety courses to more therapy oriented packages, e.g. types of disorders, stages of development. National occupational standards have now been defined. These are the basis of a formal qualification which has been developed within the Scottish Vocational Qualifications Award at level 3.

Role of the Speech and Language Therapist when working with adults with learning disabilities and/or autistic spectrum disorder

Principles

44. The key principles that underpin good practice for Speech and Language Therapy provision for adults with learning disabilities are:

• Speech and Language Therapy service delivery needs to be committed to the promotion of independence, choice, inclusion and civil rights.

• Speech and Language Therapy service delivery should consider communication needs in the context of a social model of disability.

• The practical delivery of Speech and Language Therapy services to adults with learning disabilities should be in line and in partnership with local policies, resources and priorities.

• All modalities of communication should be valued, respected and promoted by Speech and Language Therapists. An inclusive communication environment should be facilitated which will allow for the client's specific needs in terms of the format and style of presentation of visual and auditory information.

• The Speech and Language Therapist will recognise the need for respecting quality of life whilst maintaining optimum nutrition and safety during eating, drinking and swallowing.

• Speech and Language Therapy service delivery should maximise service user involvement at all levels,
  e.g. with regard to Person Centred Planning, consent and advocacy.

• A collaborative approach to service delivery across agencies, professional groups and also across the lifespan of people with learning disabilities is recognised as essential.

• All Speech and Language Therapy intervention must be linked to the life aims of the individual in agreement with identified priorities.

• Speech and Language Therapists need to be committed to contributing to the growing evidence base through reflective practice, research, clinical supervision and clinical networking.

Process for Working with Adults with Learning Disabilities

45. In order for Speech and Language Therapists to maximise the communication and/or eating drinking and swallowing skills of people with learning disabilities, they must deliver their services within the client's wider environment, and work closely with other health and social care professions. Adults with learning disabilities can access Speech and Language Therapy services from many routes. Many people with learning disabilities will require support with their communication or eating, drinking and swallowing skills throughout their lives. Most services operate an open referral system. Therapy will often be provided as episodes of care with clearly identified aims and measurable goals.

46. A variety of approaches are likely to be used, and these may include one or more of the following:

• Assessment and evaluation. The assessment will take into account the individual's life experience, their communication ability and understanding, their environmental constraints and opportunities and the potential for change. The Speech and Language Therapist will explore communication within the context of different life opportunities for people with learning disabilities and their carers.

• Intervention may be direct (individually or in a group), working with the client, and/or indirect, working with the communicative environment. Following a period of intervention, when the identified aims have been achieved, the client will be discharged from therapy but may require further involvement with Speech and Language Therapy throughout his/her life.

• Providing advice, consultation and co-working with others. The Speech and Language Therapist may act as a specific resource for issues concerning communication, through involvement with health, education, private and voluntary sectors, the work place, housing, community facilities and involvement with inter-agency initiatives. The purpose of this is to overcome communication barriers, which impact on people's choices, social inclusion, civil rights or independence.

• Training and teaching. Speech and Language Therapists play a pivotal role in communication training for other professional and carers.

• Service development. Speech and Language Therapists can take a proactive role in highlighting the communication issues inherent in delivering high quality services for people with learning disabilities.

Service level

47. In order to be effective the Speech and Language Therapist working in the field of adult learning disability will be involved in providing a service at three levels. The level of the:

• Person - intervention is based on addressing communication skills through individual work.

• Environment - where there are changes in people, processes or settings within a person's (or group of people's) environment, which will increase the individual's inclusion in social networks.

• Community - where the level of communication activity for adults with learning disabilities can be increased through attitudinal or cultural changes within the local community.

Role of Further and Higher Education in the supply of therapists and clinical support workers into the workforce

48. Four Higher Education Institutions in Scotland provide pre-registration education and training to those wishing to train as Speech and Language Therapists, Occupational Therapists and Physiotherapists. The following routes to professional registration are available:

Occupational Therapy

49. Under-graduate pre-registration education in OT is available at Glasgow Caledonian University, Queen Margaret University College and Robert Gordon University. All offer a 4-year BSc honours route and GCU and QMUC offer a 3-year BSc route.

50. GCU and QMUC also offer pre-registration education to people who already have a first degree. These post-graduate courses last between 2 years and 27 months when full-time or 3 ¹/ ² years when
part time.

Physiotherapy

51. Under-graduate pre-registration education in PT is available at Glasgow Caledonian University, Queen Margaret University College and Robert Gordon University. All offer a 4-year BSc honours route.

52. All three institutions also offer pre-registration education to people who already have a first degree. These post-graduate courses all take 2 years to complete on a full-time basis.

Speech and Language Therapy

53. Under-graduate pre-registration education in SLT is available at Queen Margaret University College and Strathclyde University. Both offer a 4-year BSc honours route and Strathclyde University offer a 3-year
BSc route.

54. There is no post-graduate education of SLTs in Scotland.

Funding of post-graduate education

55. In Scotland, unlike England, a post-graduate student is not eligible to have course fees paid and has to fund the course him/herself.

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