Written evidence submitted by the Royal College of Speech and Language Therapists (CBP0010)

Summary

1.1. The Royal College of Speech and Language Therapists (RCSLT) is pleased to make a submission to the Health and Social Care Committee’s inquiry into “Clearing the backlog caused by the pandemic”.

1.2. Throughout the UK, speech and language therapists (SLTs) have worked tirelessly to ensure that people with COVID-19 receive interventions and rehabilitation, both within and beyond intensive care units, to support immediate and longer-term recovery of communication and swallowing problems and respiratory management. 

1.3 RCSLT’s recent “Build back better report [1]” identified that many of those who did receive speech and language therapy before COVID-19 had it stopped during lockdown or delivered in ways that were difficult for them to access. We also know that health inequalities have widened, significantly exacerbating existing speech, language and communication inequalities that have existed for too long, particularly in areas of social disadvantage and amongst certain ethnic groups. We know that in some cases the innovations of telehealth have been positive. However, this not the solution in every situation, digital poverty and a lack of digital literacy are factors, as are the particular condition a person has or the age of the person with a communication or swallowing need, at both ends of the age range.

1.4. The scale of backlog, unmet needs and increased demand post Covid, that we have identified from initial discussions with speech and language therapy services, suggests a minimum increase in the skilled workforce is required in the region of 15%.  In recent years the profession has grown by 1.7% net per year. While it is encouraging that applications to speech and language therapy pre-registration courses have risen in the last two years, those additional SLTs will not be available in the short term, nor in the numbers needed. It is vital that in this scenario the profession is supported practically and financially in rapid upskilling and enhanced continuing professional development (CPD) for existing SLTs to try and bridge that gap.

1.5 RCSLT is calling for the following:

National and local recovery policies must identify and provide appropriate response to an individual’s needs and specifically:

Speech and language therapy services must be appropriately resourced to ensure that:

1.6 It is important to note that not all SLTs work in the NHS, many work in schools, in community settings, in justice and in the independent sector. We are seeing increased demand for SLTs across these areas too, for example, in prisons and Youth Offending Teams, and as registered intermediaries for the Ministry of Justice. In particular, the independent sector is currently reporting that demand is outstripping their capacity. Not all new SLTs will enter the NHS so it is important to factor this in to planning.

 

2.0 What is the anticipated size of the backlog and pent-up demand from patients for different healthcare services including, for example, elective surgery; mental health services; cancer services; GP services; and more widely across the healthcare system?

2.1 Children and Young People

We have looked at very different children’s services in Scotland and England who have modelled (and had accepted) a recovery business case for additional SLTs. These suggest that if replicated across England’s population, somewhere between 5% and 15% staff uplift is required to clear waiting lists in children’s services alone.

As a result of the NHS Long Term Plan, NHSEI established the Children and Young People’s Transformation Programme. As part of this, supporting improvements in speech, language and communication has been identified as a priority within the Keeping Children Well workstream. Recent evidence consistently indicates that community paediatric speech and language therapy services in England are unable to meet current demand:

This situation has been exacerbated by the COVID-19 pandemic:

This has led to many services experiencing a significant backlog of demand, with growing waiting lists, and late referrals for children with a high level of need. Recent meetings with the network that represents members working in the independent sector has highlighted that demand is outstripping supply with respect to SLT workforce capacity.

In order to address the impact of the pandemic, as well as the historic issues of under resourcing in the public sector, a number of things need to be put in place in parallel:

2.2 Mental health

The RCSLT expects to see increasing numbers of people seeking mental health support following the impact of lockdown and the pandemic. Sixty per cent of people in mental health settings have communication needs. In response to a RCSLT survey [3] on people’s access to speech and language therapy during the first UK-wide lockdown, 56% of people aged 18 and over said have less speech and language therapy had made their mental health worse; the figure for those aged 0-18 was 45%.

RCSLT recommends a SLT in every mental health team/service, but current SLT provision to adult mental health is patchy. Dysphagia (eating, drinking and swallowing difficulties in infants, children and adults) patient safety alerts and the need to reduce restraint, drive the demand of SLT in mental health.

Children and young people’s mental health is also a specific priority within the long term plan. The RCSLT recommends that SLTs are embedded in all relevant children and young people’s mental health services, but as with adult services, current SLT input to CAMHS is extremely variable. The impact of the pandemic is expected to increase demand for children and young people’s mental health support, and speech and language therapists have an important role to play for the significant group of children who have both mental health disorders and communication needs.

2.3 Respiratory

The NHS Long Term plan (2019) includes respiratory as a clinical priority and a focus on respiratory workforce. SLTs working in upper airway disorders are members of a specialised respiratory multi-disciplinary team (MDT), and it is recommended they should be commissioned as such. It is estimated that around 5.5 million individuals may benefit from access to speech and language therapy provision to support asthma and chronic cough, not including children.

There is a notable increase demand for speech and language therapy provision to support respiratory services.  In a recent survey of all hospital and community healthcare centres in England, the most identified barrier to treating patients with upper airway disorder were service delivery constraints (Haines, 2019). Assuming all respiratory secondary care centres and those with integrated respiratory care services had adequate access to speech and language therapy, more than double the current number is required.

Increasing capacity through implementation of appropriate training and supervision structures for newly qualified/junior (band 5/6) SLTs will enable individuals within these roles to provide therapy delivery. This would further create new routes into the respiratory workforce and enable upskilling of the workforce to increase workforce capacity in the long-term. 

2.4 Cancer

Treatments for cancers of head and neck can result in changes that affect the person’s ability to speak or use their voice. Swallowing difficulties occur before, during and after treatment due to the effects of surgery and /or treatments such as radiotherapy or chemotherapy. Due to the impact of the pandemic SLTs are seeing more patients presenting with more advanced cancer who will require more rehabilitation.

Guidelines from the British Association of Head and Neck Oncologists (BAHNO) Standards 2020 require a named SLT in every MDT, sufficient to cover leave and absence and spending at least 50% of their time on head and neck cancer. A recent bench-marking exercise conducted by RCSLT members across eight centres showed that four fell short of this minimum staffing.

2.5 Stroke

The new NHS England stroke service model includes assessment or treatment by all specialist therapists, including SLTs within 24 hours of admission, that a dysphagia management service must be available and that each patient should receive 45 min of therapy per day.

More SLTs are required to meet the requirements of the new service model:

          The workforce will need to be expanded to meet the national target of a 7-day service. Most SLT services offer a 5-day service, on the last data count, only 22% of SLTs worked in either a 6 or 7 day service.

          Local audits have shown that in order to meet the needs of patients requiring 45 minutes of therapy per day, that more resource is needed than the current staffing levels.

          Most patients do have a swallow screen within four hours by a trained member of the MDT.

          However, ensuring assessment by a speech and language therapist within 24 hours of admission will be a challenge in many units as 7 day service provision and increase in resources will be needed. The current target is 72 hours for a specialist assessment.

          It may also be a challenge to ensure a complete dysphagia management service is available, including access to services to insert a gastrostomy tube where indicated within 72 hours of decision.

          RCSLT has recommended one SLT per ten acute stroke beds, but many stroke units across the country are falling short of this level.

 

2.6 Community discharge

People who received acute or intensive care treatment for COVID-19 may suffer from a whole range of associated problems. The consequences of life saving interventions such as sedatives, mechanical ventilation, intubation, oxygen therapies and tracheostomy may lead to longer term problems, including:

 

This requires appropriate diagnosis and management, as part of a rehabilitation package. COVID-19 patients are being discharged into the community with these complex and ongoing needs, indicating a clear role for both immediate and long term involvement from speech and language therapy. Please see section 8 for estimates of the impact on the workforce.

RCSLT is also supporting a pilot to reduce the pressure on GPs with respect to meeting the needs of people in care homes. Dysphagia is prevalent in care home residents. The side effects of medications, such as mental health medications, can lead to swallowing problems. Up to 19% of hospital admissions of people with dementia could be prevented by contributions from a SLT at an earlier point. HEE has part funded and currently host the dysphagia guide which has now been ‘launched’ over 30,000 times and has been accessed by a range of healthcare workers.  Investment to support the implementation of the Eating Drinking and Swallowing Framework would ultimately reduce preventable deaths, as it upskills the wider workforce in dysphagia management.

SLTs can provide telephone triage to care homes managing the communication and swallowing problems of those in their care, removing the need for a GP visit. They provide training to care home staff and others to manage decline in swallowing performance from age and disease. SLT intervention is proven to reduce morbidity, mortality and prevent hospital admissions. SLTs have also been developing telehealth solutions in this regard.  Evidence from a telehealth project in care homes has indicating savings of £60 on each tele-swallowing assessment.

Additional SLTs in each local authority area are required to support discharge for a frail elderly population.

 

3.0 What capacity is available within the NHS to deal with the current backlog? To what extent are the required resources in place, including the right number of staff with the right skills mix, to address the backlog?

The negative impact of COVID-19 on early assessment and intervention has resulted in patients presenting with a higher level of need such as post stroke, cancer and neurodegenerative conditions. This is likely to be an issue for the next year or two. In addition the backlogs from pent up demand and previous unmet needs (detailed above) mean that it will be important that the profession is supported in rapid/enhanced CPD and upskilling to bands 6 and 7 in particular, where we are seeing growing vacancies. It is important to deal both with short term supply needs and in the longer term build those career routes. As a small profession, we would welcome support in this rapid development and implementation of new competencies in key priority areas.

An example in one area is SLTs working in ENT/Voice. They are reviewing with ENT colleagues management of the increase in referrals and waiting times, which have been doubly impacted with the long COVID patients. There are several competencies that a specialist SLT in head and neck cancer would need to achieve to be fully competent; Videofluoroscopy, FEES; Surgical Voice Restoration; Tracheostomy; Dysphagia.  It would normally take around 2/3 years to become fully independent. Training more SLTs in this role will require substantial investment in post-graduate training and supervision. This is an issue across a number of clinical areas beyond just head and neck cancer.

With support from NHSEI and HEE, this model could equally be investigated for other areas, for example, the expanding caseload of autistic people, who are awaiting diagnosis and intervention. SLTs as a profession have the skills and knowledge to support assessment, diagnosis and management, which could support the vacancy rate in medical colleagues currently.

Please see section 2.1 in relation to children’s services.

 

4.0 How much financial investment will be needed to tackle the backlog over the short, medium, and long-term; and how should such investment be distributed? To what extent is the financial investment received to date adequate to manage the backlog?

Currently there is no defined funding at a national level supporting Covid backlog clearance or long Covid in relation to SLT.  Some services are making bids internally for funding, but we suggest there needs to be a more strategic approach. In particular we note from RCSLT’s Build back Better report, that health inequalities have widened, 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. Our survey found that a higher percentage of people of all ages in the most deprived areas in England received less speech and language therapy during lockdown than in the least deprived areas.

In the short and medium term funding is required as follows:

 

5.0 How might the organisation and work of the NHS and care services be reformed in order to effectively deal with the backlog, in the short-term, medium-term, and long-term?

The NHS & Care Bill is undoubtedly an opportunity to bring greater coherence and integration, and for certain services and conditions provides a population base that will aid planning. There is a risk, however, that the focus will remain solely on NHS provision and the NHS workforce given the different NHS ICS and local partnership bodies proposed. The chance would be missed to plan for the whole health and care economy and workforce in an area. The more joint commissioning and holistic planning is undertaken, for example with local government including education, and with the independent sector, the greater the contribution to clearing the backlog will be.

The new statutory arrangements will also need to fully involve all health and care professions, and ensure that children’s and rehabilitation and primary care services are properly considered.

 

6.0 What positive lessons can be learnt from how healthcare services have been redesigned during the pandemic? How could this support the future work of the NHS and care services?

6.1 Technology

The adoption of new ways of working since the onset of the pandemic, including greater utilisation of technology and digital in service delivery, has provided an opportunity to consider alternative methods of managing demand and improving productivity. New ways of working have the potential to improve the collaboration and communication between professionals and models of service delivery that involve the use of telehealth have the potential to improve productivity by reducing travel time for both professionals and service users. Nevertheless, RCSLT members have voiced concerns that delivering interventions via telehealth may not increase productivity due to the additional time to prepare for sessions (compared with face-to-face methods of delivery), as well as concerns about digital exclusion and the appropriateness of this method of service delivery for individuals with certain communication needs. It will be important to ensure that patient outcomes and patient experience are considered alongside any gains from a productivity perspective.

6.2 Job planning

Job planning provides an opportunity to model the capacity available to services in meeting the needs of the population served, by providing insight into the available clinical hours across the service and whether this is sufficient to meet the level of demand. Services utilising job planning should therefore be better equipped to determine whether they are making best use of resources and to identify a shortfall/surplus. Another benefit of job planning is that it promotes the importance of non-patient-facing activities that are essential in delivering a high-quality services in the longer term, such as CPD.

 

7.0 What can the Department of Health & Social Care, national bodies and local systems do to facilitate innovation as services evolve to meet emerging challenges

Local ICS’s need to be mandated to ensure they all include representation from the Allied Health Professions and that all AHPs are able to feed in expertise on system needs.

We welcome previous support from NHSEI and HEE in helping the profession with specific projects to help innovation and progression in services.  That support remains essential post pandemic in developing responses to Covid backlogs and therapies, in meeting significant levels of unmet needs in the system across all services (see section 2 above).

 

8.0 To what extent is long-covid contributing to the backlog of healthcare services? How can individuals suffering from long-covid be better supported?

8.1 Long Covid and rehabilitation

The ONS recently reported that an estimated 1 million people were living with long COVID in the UK, of whom 192,000 found that their ability to undertake day-to-day activities had been limited a lot. Furthermore, around 90% of people living with symptoms will require support from a range of different rehabilitation professionals. The long COVID needs identified by SLTs included dysphagia, dysphonia, dysarthria, aphasia, cognitive communication disorder and dyspraxia. It is also critically important that rehabilitation support for people living with long COVID does not come at the expense of non-COVID rehab demand.

 

We would estimate that for every 180 referrals in the community we would expect to see 1 extra SLT recruited – probably at band 6 or 7 given the skills set required. It is clear, that given the scale of long COVID, the numbers of additional SLTs required will be in the hundreds of additional, well skilled SLTs.

8.2 Long Covid and ENT caseload

A significant number of long COVID patients are now presenting to ENT/voice clinics with voice and persistent dysphagia (muscle tension dysphagia). These people have need for significant amounts of speech and language therapy input.

Based on the number of referrals being received by one ENT/voice clinic, it is estimated that at least one additional SLT will be required in every ENT/voice clinic to deal with the backlog of patients and those with long COVID.

 

9.0 About the Royal College of Speech and Language Therapists

9.1. 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 17,000 SLT members. We promote excellence in practice and influence health, education, employment, social care and justice policies.

 

Sept 2021


[1]  Building back better: Speech and language therapy services after COVID-19  https://www.rcslt.org/get-involved/building-back-better-speech-and-language-therapy-services-after-covid-19/

[2] The impact of Covid-19 on School Starters: Interim briefing 1 Parent and school concerns about children starting school April 2021
https://educationendowmentfoundation.org.uk/public/files/Impact_of_Covid19_on_School_Starters_-_Interim_Briefing_1_-_April_2021_-_Final.pdf

[3] RCSLT survey: Impact of the pandemic on service provision https://www.rcslt.org/learning/covid-19/rcslt-survey-impact-of-the-pandemic-on-service-provision/