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Investigating SLT in Cleft Care

This study explores the variability in local and regional Speech and Language Therapy provision for children with cleft, focusing on service characteristics, waiting times, enabling factors, constraints, and current trends in the field.

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Investigating SLT in Cleft Care

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  1. InvestigatingSLT in Cleft Care Lorraine Britton, Sam Calladine, Helen Extence & Marie Pinkstone On Behalf of Lead SLT Group March 2016

  2. Background Concerns raised about NHS SLT provision in cleft care by • CLAPA • Clinical Directors • NHS England Clinical Reference Group Gap between CCG & specialised commissioning

  3. Aims to investigate: • The variability in local and regional SLT provision for children with cleft? • Local service characteristics & dosage of SLT currently being offered? • Waiting times for SLT? • What currently supports and constrains SLT service delivery to children with cleft? • The interface between local & specialist SLT services?

  4. Method • 2 Surveys circulated in Dec 2015 • Survey A. To all local SLT services in England & Wales • Survey B.Completed by Regional Teams • 11/11 regional surveys returned • 75/150 (50%) local surveys returned • Thematic Analysis of open questions

  5. Regionally funded SLT Posts

  6. Specialist SLT funded by Specialised Commissioning

  7. No. of Cleft Births per regional specialist SLT (wte)

  8. Locally Funded SLT for children with cleft • 42% (31/75) designated SLT sessions for cleft. Band 5-8c • Grading depends on rest of post e.g. leadership/other specialisms • 58% (43/75) no designated SLT sessions for cleft • All SLTs see chn with cleft • Named link SLT with some specialist skills often within a more specialised paediatric post at band 6/7 • Loss of previous designated cleft sessions

  9. Provision of SLT by Local Services

  10. Regional Variability in Models of Service Delivery

  11. Local SLT: Service Delivery Characteristics

  12. 2a. If direct therapy is needed, what is the average waiting time between identification of need and offer of therapy? Massive inequity (immediate-12 months+) Main Responses fall into 5 categories • Immediate (5/75, 7%) • 2-8 weeks (38/75, 51%) • Up to 18 weeks (18/75, 24%) • Over 18 weeks (11/ 75, 15%) • Variable (12/75, 16%) • “No direct therapy possible” (3/75)

  13. 2b. Is there any prioritisation system for children waiting for therapy? • 33% (25/75) local SLT services operate a formal prioritisation system for therapy • All Client groups • Weighting severity of problem & impact on child • 15% (11/75) of local SLT services rate children with cleft as a higher priority • 48% (36/75) no formal prioritisation system • Some SLT services are commissioned to see children in strict order of date of referral rather than clinical need

  14. 3a. What currently enables & supports your local SLT service to deliver therapy to children with cleft in your area? • Free Training for link SLTs / Local SLTS (79%) • Joint Sessions & liaison clinics to plan therapy (at regional centre / locally) (65%) • Easy access to specialist advice & support from regional centre (60%) • Designated local SLT sessions for children with cleft (41%) • Local Link SLTs with specialist expertise and ideally designated cleft sessions (30%) • Specialist provision of individual and group therapy from regional centre (22%) • CPD opportunities in cleft (19%) • Local support from more experienced SLTs (16%) • Clinical resources and leaflets provided by regional centre (12%) • “The regional team are understanding & supportive about local pressures”

  15. 4. What are the current constraints / limitations to delivering therapy to children with cleft in your area? • CASELOAD DEMANDS (73%) • Lack of designated / local specialist sessions for cleft (37%) • Down grading of posts, • Retirements not replaced, • Loss of previously designated sessions • Commissioning arrangements reducing flexibility for SLTs and reducing provision of direct & regular therapy by SLTs (19%) • Funding issues (16%) • Lack of skills & expertise for cleft (9%) • Large geographical areas and distances from regional centre reducing options for access to specialist care (9%)

  16. 5. Does your service have any protocols or guidelines that influence service delivery in any way • DNA policy (60%) • Age limited packages of care • No direct therapy before 4 yrs (2) • No SLT after 5yrs unless additional needs (2) • No SLT after 11yrs (11/64, 17%) • 6-8 week on/off blocks of therapy (12/75, 16%) • Limitation on annual no. sessions (4/75, 5%) • Consultative only services (3/75) • Tightly commissioned service provision

  17. Comments from SLTs “Cleft are the only children to get direct therapy with an SLT. The rest are seen in groups of by an SLTA” “We have no capacity to offer regular therapy” “current POC focus on skilling parents & TAS & not delivering direct therapy”,

  18. Current Trends in SLT • 30% reduction in band 8 posts • Restructuring • Downgrading • Redundancies • Private Providers • Virgincare - Surrey • Speakeasy- Notts • Do we support?

  19. Commissioning based on EBP….Or not? Evidence supports therapy for chn with SSD Baker & McLeod (2011)Narrative Review of 134 studies Research on SLT in cleft care is limited but shows the beneficial effects of therapy Bessellet al (2011) Systematic Review-16 studies NHS SLT Provisionvery different from effective SLT research • Effective: 2-3 sessions of therapy per week for 3-46 months , conducted by a skilled SLT (Baker & McLeod, 2011) • Ineffective: 6 hours SLT annually (Glogowskaet al, 2000) Typical Dose in Cleft Care – Not Evidence Based • 3-12 hours with an SLT per year (Britton, 2012; Britton et al 2016) • No evidence: 6 week blocks or consultative models of SLT

  20. CLAPA: How do you think not getting SLT has affected your child? We have had 5 different SLTs. There is no continuity and each SLT has a different way of teaching…. We waited 6 mnths for an appt and now we are finally getting seen it’s a different lady every time and there are sometimes 12 week gaps between sessions My son was getting 6 sessions then going back on a waiting list which made SLT more difficult… We saw our old therapist once every few months, and this has impacted hugely on his learning Speech Therapy provision is not standard across the country, timing of intervention and resources available differ according to local practice

  21. Leanne’s Story • SLT from 2-6 yrs • Severe glottal pattern & VPI • Weekly specialist SLT at centre meant missing half a day at school, travel, bringing siblings, rearranging work, tired • Intensive groups meant not booking hols • Local SLT less tiring but frequent change of SLT, no support for unskilled TA, staffing issues, gaps between sessions, little progress, • Now a 10 yr old with clear articulate speech

  22. Summary: The Bad News • Inequity in SLT provision locally& regionally • SLT services are commissioned & provided based on cost & demand rather than EBP • Systematic dilution of SLT services & down grading of posts • Many children seen by generalist SLTs often without local specialist clinical leadership • Lack of DIRECT, REGULAR, INTENSIVE therapy • Loss of SPECIALIST SLT • Children’s Speech Outcomes are at risk

  23. Summary: The Good News • Cobweb of Goodwill in cleft SLT • Regional specialists work closely with local SLTs to provide integrated care • Local SLT services appreciate regional support, expertise & training • “Hub & Spoke” Model for future

  24. A model for the Future? • Specialised commissioning to fund “link” SLT sessions in ALL centres • “Links” to provide therapy within local SLT services to children with cleft • Local SLT support to continue • Ensures more equity of therapy proivision • Less at mercy of local SLT services

  25. Discussion • How can we ensure all Regional Centres have a similar level of specialist SLT funding? • How do we ensure equal access to SLT for a nationally commissioned locally delivered service? • Given the limitations of our influence, should we continue to try and influence / ring fence local SLT provision or to provide more from the centres instead? • What are the advantages & disadvantages of different models of service provision? • How do we work with private agencies?

  26. “Knowledge is power” Thank you Lorraine.britton@nuh.nhs.uk

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