work from what clients want and what evidence suggests you should provide
2. be aware that the same route to an end place doesnt suit everyone
3. build in opportunities to stop over, divert and revisit as needed
4. act in partnership with voluntary agencies and other professionals
5. aim for equity and consistency through shared standards
6. increase confidence through being organised and transparent
7. ensure adequate induction and updates for staff in new procedures
8. think about the benefits of generic groups for clients
9. make specialist opinions accessible.
Practical points: care pathways
l am negotatng
care pathways
Too oten, speech and anguage therapy
and other servces are dcut or cents
to access and negotate, and therapsts them-
seves are not aways cear whch way to
turn. Do care pathways oer a way ahead'
are pathways are becomng amar to us as
a way o descrbng, pannng and mappng a
cents journey va derent routes rom
reerra to dscharge. Dependng on the
nature o the cents needs ths journey may
be through speech and anguage therapy
ony, or nvove a range o heath and
assocated servces workng together wth the
cent and amy.
But how do we know ths snt yet another
ad' Are there practca benets or cents
and servces' Do care pathways hep us to
acheve evdence based practce' And how do
we ensure that a care pathway oers easy
access or a, and snt a euphemsm or
passabe wth care'
Our two contrbutors descrbe how care
pathways can be a transport network
worthy o our nvestment.
Neil Smith is a specialist speech
and language therapist with
Portsmouth City NHS Primary
Care Trust at Rowner Health
Centre, Gosport, Hants,
tel. 023 92 511500,
e-mail smuff70@hotmail.com.
Cecilia Yardley is Director of
Services for Speakability, 1 Royal
Street, London SE1 7LL,
tel. 080 8808 9572,
e-mail
speakability@speakability.org.uk.
The charity Speakability exists to
reduce the barriers faced by
people with aphasia.
you
need to spread your
expertse more wdey
want to pass more power
to servce users
ke to be organsed n your
approach
Read ths
how l...
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003 (
Therapists had highlighted that writing reports for children with fluency
problems was difficult, therefore a fluency report format identifying areas
which should be commented on was introduced.
Equity of service
By this time joint assessment clinics were being used successfully within
the department but there was a lot of information I wanted to share
with staff, and I had to find a way to present it. In the end we decided
that, to ensure equity of service, all therapists should have access to
what is now called a fluency pack when assessing children who present
with dysfluency (figure 2). It is designed to be in line with current
research and flexible in that, if new or updated information becomes
available, it can be adapted quickly.
All new staff to the trust spend a session with me as part of their induction
to provide an overview of the service for dysfluent children. This time is also
used to discuss the fluency pack and standards. All community clinics now
have a fluency pack and specific training is arranged regularly - approxi-
mately every three months - for new staff to attend and for any other staff
members who have not previously attended or would like a refresher.
Alongside this course I recommend therapists attend another training
package, an overview of therapy approaches. This looks at the assess-
ment procedure and appropriate management for dysfluent children and
teaches intervention techniques and strategies the therapists can actu-
ally use (slow speech, modification, interaction therapy) as well as
informing them of approaches such as Lidcombe, McGuire and Starfish
which can be used by other people. This is so they have a minimum level
of awareness and understanding of several approaches and can refer on
if need be or if specifically questioned by parents. Therapists are advised
to contact me in the first instance if parents request further information.
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003
how l
y appointment three years
ago as a specialist in stam-
mering was a new venture for
me. Dysfluent children make
up a small percentage of a community ther-
apists caseload, adults with a stammer even
less, therefore specialist training in dysfluency
is not a priority. Yet our knowledge of stammering and how to manage
it is constantly growing and we know that timely, appropriate interven-
tion for children works (Christie, 1999). I had a daunting task in only
three sessions a week, but the job description gave endless opportunity
as it stated that I should ...develop the service for dysfluent children....
My first priority was to devise short and longer-term aims for the service
(figure 1). Initially, I distributed newsletters to help share stammering
related issues and to keep fluency at the forefront of therapists minds.
The newsletters informed staff of times I would be available for discussion
and highlighted small projects I was working on such as collating clinic
resources and equipment lists. They also included resources that I had
available and information on current theory.
Allowing therapists access to my specialist time was at first difficult to
achieve as colleagues had children they wanted to discuss urgently or see
jointly. In the beginning I used my fluency sessions to see children with their
community therapist to help with the backlog of such cases. However it soon
became apparent that this was very time-consuming, involved extensive
travelling across the trust and was erratic with regard to service delivery.
To deal with this, I subsequently developed joint assessment clinics.
Portsmouth City NHS Trust is split into three wide geographical areas. I
devised a rolling joint assessment programme so that one day per month
was arranged whereby if therapists had any particular problems with any
child they would refer them via a standard form to the clinic where we
would see them together (January - division 1, February - division 2 and so on).
These sessions gave therapists specific and structured access to my spe-
cialist time. Joint assessment clinics gave therapists working in the com-
munity time to discuss cases in greater depth with me in order to develop
a structured management plan. In effect, they became practical training
sessions giving staff confidence in working with this client group and
information which could be applied to other cases in the future.
To address longer-term aims, trust-wide standards were developed to
ensure consistency and equity of service across the department. These
were in line with current evidence based practice. Standards were pre-
sented in a flowchart format to give therapists visual guidance to help
the assessment procedure.
The standards include diagnostic criteria of beginning, borderline,
intermediate and advanced (Guitar, 1998) and a profile of risk (amend-
ed from Cook & Botterill, 1999). The parental interview and language
based assessments were deemed compulsory.
N
Unbockng
the pathway
How do you deveop a specast servce or chdren who
stammer n three sessons a week' Ne Smths work on a
care pathway or dysuent chdren n Portsmouth coud
be equay apped to other communcaton dcutes
whch have a ow ncdence n communty caseoads but
need targeted and tmey nterventon.
Figure 1 Short and longer-term aims
short-term aims:
1. to increase awareness of stammering related issues within
the department
2. to develop therapists confidence in working with this client
group
3. to give therapists access to specialists time (informal and formal).
longer-term aims:
1. to develop equity of service
2. to encourage skill mix and ongoing confidence
3. to provide a service which is in line with current practice and
research
4. to provide appropriate training packages to staff.
Figure 2 Contents of fluency pack
- procedures when working with dysfluent children
- pre-assessment telephone discussion
- parental interview
- child interview
- school aged screening assessment
- profile of risk (prognosis tool to be used with all new referrals)
- child assessment summary sheet
- guidelines for writing fluency reports
- venues / dates for forthcoming joint assessment clinics
- joint assessment referral forms
- stammering newsletters
- information / leaflets (based on those produced by the British Stammering
Association):
how parents can help young children who are non-fluent
information for referral agents
information for teachers
information for parents of children under five
what is stuttering?
stuttering prevention
ways to reduce demands on at risk children
- appendix 1 (the development of stuttering - diagnostic criteria)
- space at the back where therapists can keep copies of any information they
have seen or read which they feel is relevant and for any further information
distributed by the specialist.
l
vhch way now'
Dssatsacton wth the tme, resources and evdence avaabe
or therapy or peope wth aphasa s wdespread. Reectng on
Speakabtys oo Nary law lecture, eca Yardey argues
that, when speced wthn a care pathway, communcaton
dcutes such as aphasa become measurabe and can thereore
attract resources and provde consumers wth ammunton to
press or mproved servces.
their recovery of a sense of self and their ability to rebuild communication.
But with the shortage of therapists, we need to identify components of the
therapy experience that can be replicated by family members, friends or
paid workers who are not speech and language therapy specialists. As part
of an aphasia care pathway, Speakability would press for assessment,
review and monitoring to be undertaken by speech and language therapists,
who would also consistently have space in their schedules to pass on their
approaches and transfer skills to family members. The family could then
maximise the many hours outside the therapy session and feel confident to
disseminate effective communication strategies throughout the person
with aphasias wider environment.
The audience discussions at the 2002 lectures reconfirmed what we hear
from people with aphasia and their carers, how language problems can be
sidelined and subsumed by wider issues of stroke care. Stroke care path-
ways can be quite massive, and aphasia may only get a very small mention;
and then, of course, aphasia is caused by other conditions too. But without
getting demoralised, I think that care pathways offer an opportunity to
concretise the needs of people with aphasia. Within a care pathway, aphasia
becomes something to be measured. What is measured can attract
resources. What is unmentioned lacks attention.
Many of the calls my colleagues and I take on the Speakability helpline
are about how to access speech and language therapy services. We often
hear the client end of the problem expressed so frequently by therapists -
no time, no resources. In some cases, we explain to callers how to use the
health authoritys complaints procedure in their area, to draw attention to
the lack of provision. Explicit mentions of aphasia in care pathways could
be ammunition for the would-be service user, enabling them to apply con-
sumer pressure for more resources.
The publication of the long anticipated Royal College of Speech &
Language Therapists aphasia guidelines will also help very much in this
way. Speakability will be taking part in discussions to frame the new guide-
lines, and we look forward to feeding into the process the many comments
elicited from the lecture audiences during the post-talk discussion and
post-it exercise. For this, we stuck up three large sheets with identical
generic care pathway grids divided into the phases acute, inpatient, first
few months after onset, first year after onset, long-term. The three sheets
were labelled: What do you do now? What is your ideal service? and What
stops you delivering your ideal service? The audience responded by sticking
post-its with their comments onto the grids.
There were no real surprises in response to What stops you delivering
your ideal service? Time, lack of financial and human resources and the
conflict with dysphagia work all featured very heavily. This is, of course,
grist to Speakabilitys campaigning mill, and we will take forward these
and other points raised to the Royal College of Speech & Language
Therapists guideline development discussion and to a parliamentary event
scheduled for June as part of Speak About Aphasia Month.
Thriving generic group
One of the questions raised in the discussion in Edinburgh is whether ther-
apists need to start thinking more about the generic problems raised by
language loss. A member of our Scottish audience described a thriving
generic communication problems support group. This approach has also
been successful elsewhere. Where numbers of people with any particular
condition are low, and many of their problems are shared with people with
other medical labels, this approach seems to make sense. Certainly,
Speakability is aware of a great deal of common ground between people
affected by communication difficulties whatever their cause. As a friend of
mine who has had a laryngectomy commented, Being on the edge of a
conversation is the loneliest place in the world. The people with aphasia
whom I meet seem to back that up.
One of the central points for Speakability to arise from the lecture dis-
cussion is the role of the person with aphasia in developing a care pathway.
Several participants pointed out that the whole concept of a care pathway
is alien to many patients and their carers. They commented that the way
we frame care pathways may not match the key beneficiaries ways of
viewing things at all. Interventions may not be what the person wanted at
a given time - or ever - but we tend to offer what we are able to provide
(not necessarily what, in our professional judgement, the client really
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003 8
how l
needs) and to design tick box services, perhaps more to show how active
we have been than to respond to the clients individual needs.
Various members of the audience suggested that the care pathway concept
for aphasia needed to be less prescriptively linear, and more iterative and
organic. It should be designed to allow a person to return as necessary to
earlier types of intervention, and the stages should not be delineated in
terms of passing time but according to stages of psychological readiness.
Certainly, it seemed that many of the audience felt that the main push for
language therapy sessions should often be delayed for several months
longer than is currently the standard until the person with aphasia has had
enough opportunity to adjust to their new life and reach a state of readi-
ness and receptiveness for therapy. Clearly, there is pressure from relatives
in some cases - I hear it on the Speakability helpline - for therapy to start as
soon as possible so that no time is lost and as much is salvaged as pos-
sible. But if experience in many cases shows that it is more efficacious to
wait a while, perhaps six months post-onset, why not do it that way?
And the issue about the shape of the care pathway - whether it is best
modelled as a timeline or as a more iterative structure, such as a waterfall
with opportunities to return to earlier steps - also forces us to think about
the entry points to the process. Speakabilitys caseload includes people at
all times and phases along their aphasia journey. Some people contact
Speakability within days of their relative entering hospital, others some
years after discharge or if their loved one has never been in the system.
The post-it exercise revealed that, after the flurry of activity in the first few
months, the involvement of therapists trailed off significantly. I would be
interested to explore ways of achieving slow release of the therapists
expertise over the long haul of the patient getting on with their life.
Certainly one way in which this would be possible, as many of the audience
noted, would be for the care pathway to incorporate more opportunities for
speech and language therapists to share and exchange skills with other
professionals including members of the multidisciplinary team and adult
educationalists, with whom a person with aphasia might have long-term contact.
One approach to therapy that may be particularly attractive from the
patients perspective was the practice described by some members of the
audience who offer their clients a menu of therapy options to pick from,
so that their personal care pathway is negotiated with them and cus-
tomised (as much as possible) to their specific situation. As a lay person, not
a speech and language therapist, I listened with interest. What I would
take forward from that discussion is the need to research, establish and
implement what works in the issue of timing, content and mode of deliv-
ery of therapy. In my work for the Speakability information service, I would
aim to put power back into the hands of people with aphasia and their
families by adding this angle to the briefing we provide (through literature
and over the phone) about the sorts of questions they can ask about ther-
apy options. I would use aphasia care pathways on both the macro level -
to press for more resources to be devoted to interventions that work - and
on the micro level, to discuss with people what options they have for getting
the best out of the system that they can actively shape.
I think the advantage of going through a formal process of developing a
care pathway is the opportunity to have some protected time to think
about and discuss how best to provide services for people with aphasia that
match their needs and priorities. I am delighted that Lisa Hirsts example
pathway showed voluntary sector groups as partners alongside therapists.
That is how we think of ourselves at Speakability. If you would like to
explore ways in which we can work together, please give us a call!
References
Hirst, L. (2001) Pathway of care for aphasia? British Aphasiology Society
Newsletter. May.
Useful websites
Speakability (includes how to get hold of reports from the annual Mary
Law Lecture and Joined up talking, joined up working)
www.speakability.org.uk
Royal College of Speech & Language Therapists www.rcslt.org
Connect www.ukconnect.org
Headway www.headway.org.uk
Stroke Association www.stroke.org.uk