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From last to first r

Read this
if you want to work more as a team use audit to demonstrate service improvements tackle seemingly insurmountable problems
Sarah Howard and some of the paediatric SLTs involved in changing the Care Pathway

S
referral stammer: initial assessment within 6 weeks (see figure 2)

Figure 1 Care pathway - community paediatrics

peech and language therapy departments nationally have suffered from continual recruitment and retention problems for a number of years. This is particularly so in areas such as Grimsby and Cleethorpes which are geographically further from big cities and universities. (Grimsby is renowned for its fish and chips and Cleethorpes is known as the last resort.) In 1999, our small but committed community paediatrics team reached a crisis point. Following initial assessment, children were having to wait up to 24 months for further input. Our annual forward planning day in September 1999 led to brainstorming and discussions for new models of service delivery to address these waiting times and, in January 2000, a new care pathway was produced and put into operation. Complete change of anything is a frightening concept to many of us. Our experience has shown us how, by not being afraid to start from scratch, we can dramatically improve apparently irresolvable problems. As a profession we have many excellent ideas, but need the opportunity and support to express then implement them.

Moved away
We moved away from a traditional to a three stage system (figure 1). The old system consisted of a centralised waiting list following an initial assessment. Groups were only offered as an option if therapist time became available. Now, after receipt of a referral, all children are seen within a 13 week period. They are routinely offered an initial assessment of one hour at a local clinic. Where children are found to have dysfluency, severe and complex needs, or further information is required, other assessments may be provided. Children with speech sound difficulties or language delay then follow the three stage system. Following initial assessment parents are invited to a parent information session (stage 1) where other carers or professionals involved are also welcome. Two sessions are on offer, one focusing on speech sounds and the other on language development. Each lasts approximately one hour and aims to provide information regarding normal development, general strategies and specific activities for home practice. Information sheets and workbooks are provided for parents to take home. In some cases it is appropriate for parents to attend both information groups so, following completion of one parent group, they sign up for the second. Parents are provided with a choice of dates and times (including some evening sessions), and are waiting no longer than two months. Numbers are usually kept to between 6 to 15 children represented at any one session. Parents are then asked to sign their child up for a recommended speech and language group (stage 2). Children cannot enter this stage until at least one parent / carer has attended a parent information session. An increasing range of groups is being offered, such as early communication, sound awareness, and speech sounds. These cater for four to eight children and are run by one therapist or a therapist with an assistant. Groups usually involve four to six sessions carried out on a weekly basis. Early communication groups consist of one home visit, video feedback and parent training, whereas phonology groups typically

initial assessment (within 13 weeks) severe/complex (see figure 3)

Stage 1 enabling parents

parents information session: phonology

parents information session: language

Stage 2 group input

phonology and sound awareness groups

early communication SULP groups/ (Rinaldi, 1995) Hanen (Manolson, 1992) review
Stage 3 individual input

one-to-one therapy discharge 18

severe/complex

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resort
involve children and carers attending clinic together for all sessions. All children are offered a group within a target six month period. On completion the child is reviewed by their named therapist and is either invited to attend another group or to repeat the same group if appropriate, or placed on the waiting list for one-to-one therapy. This decision is made in consultation with the carers. Children who for exceptional reasons are unable to attend for group appointments bypass stage 2 and move directly to stage 3. Here, children who require one-to-one input following a review assessment receive one or more blocks of therapy and are expected to be working towards discharge.

Recruitment and retention difficulties led to crisis in Grimsby and Cleethorpes, with lengthy waiting times, poor attendance, unequal service and low staff morale. Sarah Howard and Cheryl Hughes herald the introduction of a new care pathway - and explain why the old system has had its (fish and) chips.
effect on learning potential. They will be offered further detailed assessment, one to two terms of clinic-based input with a specialist therapist, a school / nursery visit and programme, a home visit and referral on to other professionals. On completion of this package of care they may return to the community care pathway. Following a discussion between the severe and complex therapist and the community therapist, they will either enter at a relevant parent information session or be placed on a waiting list for one-to-one therapy. However, many children referred to the severe and complex caseload never return to the community system as they either receive a Statement of Special Educational Needs or enter the Child Development Centre.

Figure 2 Care pathway - dysfluency

referral initial assessment (within 6 weeks) primary aged and preschool stammerers older stammerers

Separate pathway
Children who are referred as dysfluent follow a separate pathway (figure 2). From receipt of referral they are offered an initial assessment within a six week period. This assessment may occur over more than one visit and usually contains a general screen of their global speech and language skills, a child interview, parental interview and a parent-child interaction video (Rustin et al, 1996). Following the initial assessment, preschool and primary aged children are prioritised as: no input required low / moderate risk: parent-child interaction therapy (Rustin et al, 1996) high risk: parent-child interaction therapy and/or direct work. They will then be reviewed, with homework tasks to ensure generalisation. Teenage stammerers are offered one to two packages of care, usually direct input, followed by a generalisation period of up to a year.

Comparison
The new care pathway came into operation gradually in 2000. An audit was carried out in 2001 focusing on two service standards, with a comparison made between standards achieved in 1998 and 2000. Standard One: A maximum waiting time for contact from the speech and language department of six months at any point in the care pathway. There was an increase in compliance of 11 per cent, with the 66 per cent waiting a maximum of six months for contact in 1998 increasing to 77 per cent in 2000. Standard Two: A 10 per cent decrease in the average number of Did Not Attends per child (excluding those who fail to attend their initial appointment) from 1998 compared to 2000. The actual decrease was 25 per cent, with the average number in 1998 being 1.21 compared with 0.90 in 2000. Further decreases are anticipated in the next year as the new care pathway is now fully in place and results were affected by the changeover period; for example, parent information groups were not running regularly until mid 2000, and increased sessions for running speech sound and early communication groups were not available until mid 2000. Parental expectations are now more comparable to the therapists, as this is addressed at the outset. We are seeing increased parental knowledge as shown by comments on what they felt they had learned following the parent information sessions: I know how to simplify language; I know how to help my "

parent-child interaction therapy (Rustin et al, 1996)

direct input

generalisation period (up to 12 months) discharge

Figure 3 Care pathway severe and complex caseload

An increasing range of groups is being offered, such as early communication, sound awareness, and speech sounds.

referral from community caseload (see text for critieria)

further assessment by severe and complex therapist (within 8 weeks)

Severe and complex

A child identified by a speech and language therapist as fulfilling the following criteria can be referred on to the severe and complex caseload (figure 3): involved with other agencies disordered or severely delayed speech and language skills high risk/high need children (Malcomess, 1999) no spontaneous progress

package of care (see text for details)

return to community caseload

Child Development Centre

statemented caseload

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REVIEWS
DYSARTHRIA

Figure 4 Case examples

EMPHASIS ON RETAINING HUMOUR

My Stroke of Luck Kirk Douglas Little, Brown ISBN 0 316 85998 2 12.99
In 1995, Kirk Douglas had a stroke which resulted in dysarthria and this book recounts his initial struggle to come to terms with his disability, his gradual recovery, and his determination to continue improving. It is aimed mainly towards those who have had a stroke themselves and the opinion of one such person is that it conveys a very positive and encouraging message. The emphasis on retaining humour and the Operators Manual (a guide for recovering from a stroke) were especially liked. Short chapters and double-spacing make it a fairly easy read and the inclusion of pictures and anecdotes of famous people also enliven the book. This could not be classed as essential reading, but personal accounts of stroke are always interesting and, combined with anecdotes of famous people, this is no exception. Judith Sandeman is a speech and language therapist currently working as an Area Training Co-ordinator with Chest Heart & Stroke (Scotland)

PUPPETRY

James (b. October 1996) was referred in December 2000 by his teacher due to difficulties understanding him. He attended for assessment in February 2001 and was found to have a mild global speech and language delay. His parents then attended a parent information group (language) in March. By August James was offered a place on a Derbyshire Language Scheme (Masidlover, 1979) group. At his September review he had age appropriate speech and language and was discharged. Under the previous care pathway James would have waited between 18 to 24 months after his initial assessment for any further input. This shows the benefits to him of being provided with group input within a shorter period.

Callum (b. July 1997) was referred by his GP in July 2001. At assessment in August he had a moderate phonological delay. In October he attended four out of five group sessions to work on [f]. At review in January 2002 he still had some phonological immaturities, so was placed on the waiting list for oneto-one therapy which was offered almost immediately. Callum was discharged in February following one block of therapy as his speech sounds were age appropriate. The significant benefit of individual input within such a short period is only possible due to the large number of children discharged within stages 1-2 of the care pathway. Speedy passage through the pathway allows more time to be set aside for other children, keeping waiting times down.

Harvey (b. December 1998) was referred in February 2001 by his health visitor due to his lack of language. He was assessed in April and found to have a very restricted range of single word expressive language, but age appropriate verbal comprehension and social skills. His parents attended an information session on language development in May and were then offered a place on an early communication group in June. During this group Harvey began babbling and showed an increase in turn-taking skills. In August his progress was reviewed and, due to his continuing severe difficulties, he was transferred to the severe and complex therapist who diagnosed him verbally dyspraxic in October. Harvey has continued to receive specialist input. Harvey benefited from input at an early stage and on a regular basis. Parents were provided with information and general strategies. It was then possible for further assessment and input to be offered in a group environment which was more appropriate for a child of his age and difficulties than one-to-one. This led to more appropriate referral on and accurate diagnosis. One benefit to staff is the increased satisfaction in being able to offer a child with Harveys level of difficulties almost immediate input. Previously he may have waited for an extended period with increasing levels of frustration and anxiety for both Harvey and his parents.

A UNANIMOUS COOOOL!

I am the Story (the art of puppetry in education and therapy) Caroline Astell-Burt Souvenir Press ISBN 0285636197 12.99
Puppets help expressive, receptive and pragmatic language skills in a stimulating, exciting and fun way. This book is packed with information about the different types, how to make them, what to do with them and why. The author successfully combines theoretical and practical aspects with a wide range of clients. Triumphs and pitfalls are described through case studies. Throughout, the author emphasises the importance of evaluating the way the client uses the puppet, and a simple checklist is provided to assess this. The practical exercises are invaluable to the novice puppeteer. Instructions for glove, rod and shadow puppets and marionettes are accompanied by delightful line drawings, and attention is given to how and where to work them. Subsequent sections include puppets in narrative, as surrogates, and puppets to enhance language, communication and literacy. I thoroughly recommend this book which is readable, inspiring and would benefit clinicians of all ages and levels of experience. It makes you think, and inspires you to have a go. My first attempts, involving socks, buttons, beads and sponges, received a unanimous cooool! from pupils in Years 3-6 in a speech and language unit. Jill Spring works in speech and language bases in Dorset, and is a member of the diagnostic team for autistic spectrum disorders.

#child

make sounds. Attendance at groups following the parent information sessions has increased. This may be the result of parents being more involved in decisions regarding their childs therapy, and also a shorter waiting period before input being offered. Many children do not go on to require one-toone input, but are discharged at review prior to stage 3. This has had a knock on effect of reducing the numbers waiting for one-to-one. The waiting time at stage 3 is less than six months and attendance has increased. Staff morale has increased and the new system has allowed greater equity between community therapists service provision. Parent training and groups are available to all children irrespective of locality or individual caseload size, and input following initial assessment is always within two months (see case examples in figure 4). It is important that we continue to monitor and modify the changes we have made to reflect the shifting changes and needs of the population to which we provide a service. Sarah Howard is coordinator of paediatric services and Cheryl Hughes a speech and language therapist with Northern Lincolnshire and Goole Hospitals NHS Trust based at the Speech and Language Centre, 34 Dudley Street, Grimsby, NE Lincolnshire DN31 2AB, tel. 01472 313212.

TASLTM Conference, Edinburgh. Manolson, A. (1992) It Takes Two To Talk. Ontario: Hanen Centre Publications. Masidlover, M. & Knowles, W. (1979) Derbyshire Language Scheme. Derbyshire County Council. Rinaldi, W. (1995) Social Use of Language Programme for Primary and Infants. Guildford: Learn-Communicate. Rustin, L., Botterill, W., & Kelman, E. (1996) Assessment and Therapy for Young Dysfluent Children: Family Interaction. London: Whurr.

Acknowledgements
A special thanks to the paediatric speech and language therapy team based in Grimsby for their hard work and support in creating and implementing the new care pathway.

Reflections
Do we provide a service that is equitable and timely? Do we make sufficient use of groups? Do we have the opportunity to express and implement new ideas?

References
Malcomess, K. (1999) Delivering Clinical Governance in Speech and Language Therapy.

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