Written evidence from the Royal College of Speech and Language Therapists (PCC0052)

HOUSE OF LORDS INTEGRATION OF PRIMARY AND COMMUNITY CARE SELECT COMMITTEE INQURY

Joint Committee inquiry into integration of primary and community care:

written evidence submitted by the Royal College of Speech and Language Therapists

About the Royal College of Speech and Language Therapists

• The Royal College of Speech and Language Therapists (RCSLT) is the professional body for speech and language therapists across the United Kingdom. The RCSLT currently has around 20,000 members. We promote excellence in practice and influence health, education, employment, social care and justice policies.
• Speech and language therapists (SLTs) deliver evidence-based care for children, young people and adults in multiple settings to identify and support their communication and swallowing needs.

Summary of submission

• There is growing un-met speech and language therapy need in primary and community services. 

• Shortages in community speech and language therapy services predate the pandemic, but have been made worse by it.
• Workforce vacancies risk patient safety and patient outcomes.[i]
• Investment in an adequate workforce, in the right place, with the right skills is critical to improve integration.
• To help achieve this, workforce planning in England for speech and language therapists must be improved, services must be commissioned and funded[ii], and barriers preventing integrated care must be removed.[iii]
• Embracing speech and language therapy in first contact practitioner (FCP) roles could help to speed up integration.

1. What are the main challenges facing primary and community health services?

1.1. Primary and community services have a key role in delivering care close to home, enabling people to live well and independently in their preferred place and helping to prevent the deterioration of health and wellbeing. However, primary and community care services are facing immense challenges.

Adult health services

1.2. Within the UK there is an ageing population. Although life expectancy is increasing, people are living more years in poor health.[iv] People with long-term conditions account for about 50% of all GP appointments, with incidence increasing with age.[v] It is predicted that by 2035 up to 67.8% of adults aged over 65 years are expected to be living with multiple health conditions, and approximately 33% of these people are anticipated to have mental health conditions, such as dementia or depression.[vi] These are conditions speech and language therapists add value to on a daily basis.

1.3 Primary care is often the first point of access into NHS services. Many people with eating, drinking and swallowing difficulties and speech, language and communication needs would first present to their GP for advice and onward referrals. GPs are cited as one of the top referrers to SLT services.

1.4 Community services are seeing the effects of the ageing population, the increasing incidence of chronic disease, earlier identification of conditions across all age groups and improved survival rates is increasing demand for their services, across all age groups. Community speech and language therapy services are faced with lengthening waiting lists, increased population need, overstretched services and workforce vacancies. The severity and late presentation of many long-term conditions, cancer, mental health, dementia and stroke post COVID-19 pandemic has compounded the waiting lists for all service providers, including speech and language therapy which was already under pressure pre-pandemic.

1.5 Primary care and community services have a vital role in relieving pressure on the rest of the system, such as supporting the safe and timely discharge of people from hospital, working to avoid hospital admissions and delivering rehabilitation. However, the challenges facing the community sector mean that, for example, if people cannot access timely speech and language therapy, they are more likely to present at a later stage with more complex needs and present in the acute sector.

1.6 The pressure to get people out of hospital can result in unsafe expeditated discharge, followed by people’s needs not being sufficiently met within primary care or the community resulting in a return to hospital. People with conditions such as dementia and COPD are being readmitted to hospital due to pneumonia related aspiration from swallowing problems, due to delays in accessing speech and language therapy in the community. This leads to family distress trying to cope with coughing, choking and dehydration/malnutrition. Poorly coordinated services are leading to this revolving door, which is costly to the system and fails to meet people’s health and wellbeing needs.

1.7 Community services are a critical element in delivering more services out of hospital and in providing care closer to home and they are a part of the latest Urgent and Emergency Care Recovery Plan. However, a continued lack of investment and focus on community services risks the ability of community services to grow to provide new models of care such as those in the NHS Long-Term Plan.

Children’s health services

1.8 The number of children and young people requiring speech and language therapy for speech, language and communication needs (SLCN) and eating, drinking and swallowing difficulties has also increased in recent years. For example, since 2014/15, the number of children and young people with speech, language and communication needs as an identified special educational need has increased by nearly 42%.[vii]

1.9 The level of funding for children’s speech and language therapy has not kept up with this increased demand; in fact, a report by the Children’s Commissioner for England in 2019 found that over half (57%) of areas in England had seen a real-terms reduction in spending on speech and language therapy in the preceding three years.[viii]

1.10 Referrals to children’s speech and language therapy come from a variety of sources, including health visitors, nurseries, schools and self-referrals from parents. There is an opportunity to increase referrals from primary care to support earlier identification and support of children’s needs (see below).

First contact practitioner (FCP) roles

1.11 The NHS Long-Term Plan committed to primary care transformation. However, additional roles in primary care, such as first contact practitioner roles, are slow to extend to provide communication and swallowing support. Existing FCP roles could be extended to include speech and language therapy, which would support growth in capacity. Recent SLT FCP pilot studies indicate that SLT FCPs working in a variety of roles, including supporting children with SLCN and supporting adults in care homes, has the potential to enhance people’s outcome and experience, reduces GP contact time, tackles waiting lists and improves quality of care across the system. The SLT FCP role has not yet been approved through NHS England’s DES/ARRDS route, but this is being addressed over the next year. Utilising this easy route via primary care would provide timely, personalised support, allowing rapid access to specialist assessment, tailored advice and appropriate onward referrals. This would also reduce primary care contacts and reduce the need for people to be referred into secondary care for further costly treatment or assessment.

2. What are the key barriers preventing improved integration, and how might these be overcome?

2.1 Having an adequate workforce, in the right place, with the right skills is critical to improve integration. The workforce required to ensure optimal patient care within the community and primary care needs to reflect the wider added value of professions other than GPs, doctors and nurses.

2.2 Having multi-disciplinary teams (MDTs) within primary care, will support better integration between sectors, supporting rehabilitation and enabling better support for people with long term conditions, frailty, or complex presentations. However, this is infrequently the current case.

2.3 There is an appreciation that there are shortages in all aspects of the NHS workforce, and not considering allied health professionals (AHPs), including SLTs, as a key part of the solution to enhancing primary and community care is a significant oversight.

2.4 A failure to include AHPs in the planning the integration and streamlining of services is a barrier to improving integration and service delivery. AHPs are the third largest workforce in the NHS. Where AHPs are represented, they visibly evidence new ways of working that improve quality, productivity and, ultimately, organisation and system sustainability.

2.5 Community services have historically been poorly understood and lacked funding and coordination. Despite the investment and advances in acute services, community rehabilitation services have not developed at the same pace.

2.6 Funding streams need to be opened up and be made available to a wider range of professions. This would not only enhance service delivery but offer innovation and richer patient experience. 

2.7 Greater understanding and priority should also be given to health services for children and young people, recognising that for children it is vital that integration occurs not only across primary and community health care, but also with early years providers, education settings and children’s social care services.

2.8 Community support for people with mental health needs also require ongoing appropriate support with skilled trained staff to recognise and deescalate any situation to avoid avoidable contact with acute services.

2.9 Navigating the system to access primary or community care is challenging, which is made more difficult if English is not a first language or with the presence of communication difficulties or cognitive challenges (for example, dementia, learning disabilities or other hidden disabilities).

3. Pressures on primary care have been well documented. How would you assess the current state of community care, in particular the integration between both areas?

3.1 One assessment suggestion is to benchmark waiting lists for community and primary care services with additional workforce mapping across each Integrated Care System (ICS) to gain an understanding of the challenge. Ensuring adding non-NHS staff working in social care, education settings and voluntary services would be strongly advised.

3.2 The pressure on primary care is well documented with challenges across GP workforce shortages and rising patient demand and numbers.

3.3 Pre-existing demands on community services have been exacerbated by meeting increased need associated with the pandemic. Demand has increased due to more people developing more advanced or severe needs due to a lack of intervention, providing therapy to people with long COVID with no extra resources, as well as supporting people who have developed new speech and language therapy needs.

3.4 Speech and language therapy services are reporting demand on their services has increased since the onset of COVID-19 in the UK, with a substantial proportion of services saying that it has ‘at least doubled’.[ix]

3.5 A consequence of increased demand on services is longer wating lists. NHS England Community health services waiting lists February 2023 statistics reveal thousands of people on community waiting lists for speech and language therapy.

• In February there were 18,869 adults on the waiting list for speech and language therapy, with 3,346 people waiting up to a year. This was an increase in the total waiting list from January 2023.
• In February there were 65,871 children on the waiting list for speech and language therapy, with 20,048 children waiting up to a year. This is the second highest of all the children’s community health service waiting lists.[x]

3.6 Alongside the waiting lists, there are significant challenges recruiting speech and language therapists to every band level. A 2023 survey by the RCSLT of vacancies in the profession found an average vacancy rate of 25% in children’s speech and language therapy services in England and 24% in adult services. Recruitment is more or much more challenging than at any time in the last three years with 96% of children’s speech and language therapy services and 90% of adult services say recruitment is more or much more challenging than at any time in the last three years. The band most affected is band 6.[xi]

3.7 This comes at a time when demand is increasing, including through:

• Children and adults of all ages receiving less speech and language therapy during the acute phase of the pandemic, as detailed in the RCSLT’s report on the impact of the first UK-wide lockdown (March-June 2020) on access to speech and language therapy, Speech and language therapy during and beyond COVID-19: building back better with people who have communication and swallowing needs.[xii]
• the sustained impact of COVID-19 on all people accessing SLT services.[xiii]
• the impact of the pandemic on young children’s development, including their speech, language and communication skills.[xiv]
• the emergence of a new clinical area – long COVID – where SLTs have a significant role to play in supporting people with the condition.[xv]

3.8 The increase in demand is having a negative impact on speech and language therapy services, the individuals that therapists serve, and indeed therapists themselves. The growing negative impact on speech and language therapists’ mental wellbeing is an area of concern. This is leading to challenges with staff retention.[xvi]

3.9 Community services vary from area to area and adult services are often siloed by condition. Not all community services contain vital speech and language therapy staff to help people with swallowing or communication needs.  Services are often uncoordinated and insufficient to meet people's needs. This allows health inequalities to persist.

4. What are the implications of the Government’s long-term workforce plan for the NHS on primary and community care staffing?

4.1 The RCSLT hopes the Plan will contain commitments to increase AHP apprenticeships, opening up entry into the profession.

4.2 There are indications that the draft plan commits to address vacancies in community nursing. We would like this to be expanded to be non-profession specific and to include a target for allied health professionals working across primary and community sectors.

4.3 The RCSLT also hopes the plan will include proposals to tackle the shortfall in speech and language therapy due the significant challenges highlighted above, most especially the significant long-term failure to properly plan – and then resource – the speech and language therapy workforce.

4.4 In April 2023, the RCSLT and the Association of Speech and Language Therapists in Independent Practice (ASLTIP), published a joint report, Fail to plan, plan to fail: speech and language therapy workforce planning in England.[xvii]

4.5 Fail to plan, plan to fail revealed that for too long, workforce planning in England for speech and language therapists has not been fit for purpose. There has not been any central workforce planning for speech and language therapy services looking across the whole profession. Planning to date has failed to take into account the different settings in which speech and language therapists work, focussed primarily on those employed in health settings, failing to take into account the different types of employers who employ speech and language therapists.

4.6 Whilst there has been increases in the number of SLTs being trained in recent years, as SLTs have a choice about whether to work in the NHS or in the independent or other sectors, more SLTs need to be trained to meet the long-term NHS need.

4.7 It is critical that any staffing projection takes into account the future workforce needed to transform services and deliver new models of care. Given the scale of speech and language therapy waiting lists and unmet and increasing need, significant growth in the skilled workforce is required.

4.8 Speech and language therapy is recognised by the UK Government as a shortage profession. In its submission to the Migration Advisory Committee’s Full Review of the Shortage Occupation List, the Department of Health and Social Care argued that speech and language therapists should be added to the Shortage Occupation List because the profession is facing a range of pressures including increasing demand, in mental health in particular.[xviii] The NHS Long-Term Plan identified speech and language therapy as a profession in short supply.[xix]

5. What is the impact of recent structural changes to the NHS in England (enacted through the Health and Care Act 2022) on integration between primary and community care services?

5.1. RCSLT members suggest it is too early in the implementation of ICSs to see impact, but the potential is being acknowledged. There is a desire to see examples from other ICS/Bs to share good practice.

5.2. System integration requires representation from community rehabilitation Allied Health Professionals. Representation is vital to ensure a strong community services perspective. It would facilitate community services having equity of voice with others. The RCSLT is concerned that there is no accountable Allied Health Profession lead on the ICB, which risks community rehabilitation issues lacking focus.

6. Is the current primary care model fit for purpose and servicing the needs of patients?

6.1 The current model is varied - and a postcode lottery. It is not well understood by service users and can lead to duplication or omission to access services. There are pockets of good practice, but many systems are still evolving in terms of primary care offers.

7. How successful have Primary Care Networks been in facilitating joined up working between primary and community care provision, and other parts of the system?

7.1 The picture of speech and language therapy interface with Primary Care Networks has been patchy. There is still a paucity of understanding of the role of SLT within the core PCN networks, however there are noteworthy exceptions. A fragmented system makes gaining access to data challenging. More detail of England wide services would be recommended.

8. To what extent could improved access to out of hours and 24/7 services contribute to alleviating pressures on the health system?

8.1. Prioritising hospital discharge rather than avoiding admission is a challenge to the workstreams.

8.2. Improved, targeted and timely access to out of hours and 24/7 care would be welcome. The current system can be difficult for individuals and families to navigate.

8.3. More focus on proactive care and hospital avoidance programmes can only be achieved with sufficient staffing of community /rehabilitation teams which are fully resourced to support the individual after the post-acute package stops. Greater consideration of rehabilitation can help to reduce unnecessary emergency admissions. These are dependent on AHP delivery and have positive clinical and financial benefit to the system.

8.4. The intermediate care pathway in development may support this but more focus on the hospital avoidance end is needed.

9. To what extent have Integrated Care Systems (ICSs) been able to deliver the aims they were set up to achieve?

9.1. Community health services are central to the aim of improving coordination and collaboration between services to meet population health needs.

9.2. However, against the backdrop of pressures across primary and community care, there is a risk that systems will focus on the immediate crisis of elective care recovery, cancer and ambulance delays, rather than broader work to improve population health. There is a risk that less time will be spent on establishing and improving how (new) community services work together.

9.3 It is unclear how the ICSs have had time or focus to understand the complexity of the paediatric systems which are an essential strand of the ICS delivery plan.

10.  Could you provide examples of how primary and community care have contributed to tackling health inequalities, including international comparisons?

10.1 Health inequalities in support for communication and/or swallowing needs have been widened by the pandemic, significantly exacerbating existing speech, language and communication inequalities that have existed for too long, particularly in areas of social disadvantage and among certain ethnic groups.[xx]

10.2 Speech and language therapists can support the tackling of health inequalities.[xxi]

11.  What can be learned from approaches to using technology during the COVID-19 pandemic?

11.1 Prior to March 2020 digital technology such as telehealth was used in relatively few speech and language therapy services. In March 2020, due to the emerging COVID-19 pandemic and the general disruption to the delivery of healthcare services, many more speech and language therapists turned to telehealth to enable them to continue to work with service users in the context of public health restrictions and because of issues related to personal and protective equipment.[xxii]

11.2 The pandemic accelerated the use of digital technology, allowing community services to try and test technology and transform services.[xxiii] (Many SLTs are continuing to use telehealth in some form as part of a hybrid model of service delivery to assess and provide intervention for service users as well as utilising the principles of videoconferencing to support meetings, training, supervision and student placements.)

11.3 The RCSLT has learnt that there are limitations with the use of telehealth, and it is important to consider age, language skills and/or cultural background, communication skills, level of literacy, hearing and visual abilities, cognitive skills and technological skills and availability and access to technology devices and the internet. It also needs to be respected that some people may not wish to use telehealth, and that individual preference and choice needs to be taken into account. Thus, the appropriateness of telehealth alone or as part of hybrid care for an individual should be decided on a case-by-case basis.[xxiv]

11.4 While digital tools have benefits for some patients and staff, a proportion of the population in England is digitally excluded or have needs that make digital access less appropriate for them. There is a clear and strong relationship between groups that are digitally excluded and those at greater risk of poor health. People from excluded groups or living in deprived areas often lack the skills, ability and means to get online. An evaluation of the NHS Widening Digital Participation Programme demonstrated that digital inclusion interventions showed a return on investment of £6.40 for every £1 spent (NHS Digital, 2020).

11.5 SLTs’ recognition and acceptance of how technology can augment practice has increased, with particular value being placed on inclusivity, choice, training, resources, leadership and indication of effectiveness.[xxv]

11.6 The pandemic also expedited innovation in technology including considerations of mobile diagnostic delivery (for examples video flouroscopy and FEES) which may enhance patient care and access.

In what way could the existing infrastructure be enhanced to improve the use of health technologies, and what are the possible benefits for patients?

11.7 There is an assumption that health and care professionals are feeling confident and fully equipped to utilise digital and health technologies to their full potential but that’s not the feedback that RCSLT captured from members. We ran focus groups and found a very mixed picture. Some SLT services are ‘digital pioneers’ and have embraced innovation and feel confident because they have been given the right tools, support and training. On the other hand, other SLT services reported low levels of digital literacy and lacking confidence in using IT tools. The lesson learnt is that education and training (pre- and post-registration) for the workforce will be an important factor in ensuring we can make the most of digital and tech for patients for the future.

How could technology harness ways to empower patients to take responsibility for their own health?

11.8 There has been a surge in people using remote health services, including COVID apps and platforms, the NHS App, NHS login and e-prescription services.

11.9 The increased focus on remote monitoring and self-management can support and empower people to take control of their own care. Examples include:

• The Big Cactus study involved self-managed computer therapy to help people with aphasia. The results showed that people with aphasia can improve their word finding with extra practice provided by a computer therapy approach.[xxvi]
• This confirmed the findings of a previous study where using smart tablets between therapy sessions can improve communication skills in people with aphasia.[xxvii]
• Another study showed that people with dysgraphia improved on a functional writing measure following therapy using assistive technology.[xxviii]

12. Could you please outline one key change or recommendation you would like to see to enable effective and efficient integration in the delivery of primary and community care services?

12.1 We need the right workforce, with the right skills in the right place to enable integration. We recommend:

• increasing community sector capacity, including strategic leadership roles for allied health professionals, to drive forward integration across primary and community care;
• longer-term planning and workforce investment with training and supervision at its heart, to ensure recruitment, retention and long-term continuing professional development; and
• the removal of barriers to speech and language therapists, and other allied health professionals, being able to deliver integrated care, for example, removing the barrier to us being able to independently prescribe where it is safe and appropriate to do so within the scope of our professional practice.[xxix]