Written evidence submitted by Royal College of Speech and Language Therapists (RTR0040)

1.0. Summary

1.1. The Royal College of Speech and Language Therapists (RCSLT) is pleased to make a submission to the Health and Social Care Select Committee’s inquiry into “Workforce: recruitment, training and retention in health and social care.”

1.2. Pre-existing demand for speech and language therapy services has been compounded by an increase in the backlog and new demand as a result of the COVID-19 pandemic.

1.3. In order to ensure that people across the UK are able to access the speech and language therapy that they need, it is vital that: (1) the necessary number staff with the right skill mix to meet demand are recruited to fill vacancies; (2) existing staff are able to access training to progress their careers and better serve their service users (3) a more thorough understanding of why staff are leaving the public sector is gained in order to improve retention.

2.0. What are the main steps that must be taken to recruit the extra staff that are needed across the health and social care sectors in the short, medium and long-term?

2.1. Both the Department of Health and Social Care and NHS England have recognised that speech and language therapy is a profession in short supply. 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.  Additionally, the NHS Long Term Plan identified speech and language therapy as a profession in short supply.

2.2. Short-term

2.3. The scale of backlog, unmet needs and increased demand post-COVID, which we have identified from 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.

2.4. Applications to pre-registration speech and language therapy courses have risen in the past two years, but these students will not be ready soon enough nor in the numbers that are needed. Therefore, it is vital that current speech and language therapists are supported practically and financially in rapid upskilling and enhanced continuing professional development (CPD) to bridge the gap in the short term.

2.5. Medium and long-term

2.6. We know that students are entering the speech and language therapy profession in increased numbers. However, the system cannot support more students unless they are supported financially, professionally, and personally.

2.7. Support for placement expansion and tariff reform is key to ensuring that students are ready to enter the skilled workforce. If increasing student numbers is a priority for Government, then there must be consideration for how the NHS and other employers will be able to provide an increased number of placements, including ensuring that staff are funded, supported, and qualified to provide supervision.

2.8. Furthermore, equality, diversity and inclusion (EDI) must be central to student recruitment in order to ensure that the profession becomes more diverse and is able to adequately support the diverse populations whom it serves.

2.9. The RCSLT is pleased to be supporting the new speech and language therapy apprenticeships that are starting from this year. To encourage uptake from employers and to support the establishment of the apprenticeship, we would like to see Government meeting the cost of backfill for apprentices while they are studying.

3.0. What is the correct balance between domestic and international recruitment of health and social care workers in the short, medium and long term?

3.1. What can the Government do to make it easier for staff to be recruited from countries from which it is ethically acceptable to recruit, with trusted training programmes?

3.2. Speech and language therapists are currently supported by a mutual recognition agreement (MRA) in regard to reciprocal training programs and regulated by the Health and Care Professions Council (HCPC) in regard to levels of general professional competency.

3.3. The MRA allows SLTs trained in a select number of other countries to take up post in the UK. It would be beneficial if Government could work with MRA countries to support these SLTs in their entry to the UK, which could help alleviate current workforce shortages. Such support could take the shape of incentives such as faster visa processing or relaxed visa requirements for AHPs or healthcare workers in general, and/or the reduction of financial barriers such as the healthcare surcharge or financial requirements for bringing a partner or children to the UK. Such efforts would also be beneficial in recruiting SLTs from non-MRA countries, although the spoken English requirements may make this more challenging than recruiting from MRA countries.

3.4. Additionally, it would be useful for Government to provide incentives and support to organisations who receive overseas workers so that they can, for example, support pastoral care for these new staff when they arrive. This may make organisations more likely to recruit health and social care workers from abroad to fill the immediate gaps and shortages.

3.5. In all cases, however, if skills are to be transferred into the UK, there is a moral obligation that Government consider the impact of this on the country of origin and the workforce challenges or shortages which they may be facing.

4.0. What changes could be made to the initial and ongoing training of staff in the health and social care sectors in order to help increase the number of staff working in these sectors? In particular:

4.1 To what extent is there an adequate system for determining how many doctors, nurses and allied health professionals should be trained to meet long-term need?

4.2. At present, the system for workforce planning only focuses on planning for the NHS, in terms of both setting and employer. It fails to take sufficient account of the support provided by SLTs outside of the NHS as well as those employed by organisations other than the NHS, and is therefore inadequate in determining how many allied health professionals should be trained to meet the long-term need.

4.3. There are around 19,500 speech and language therapists in the UK, many of whom have a portfolio career and work part-time. We estimate that around two-thirds spend at least some of their working time in the NHS. Those not working in, or employed by, the NHS may be working for local authorities, in schools, the justice sector, the third sector and in independent practice. However, these settings are not represented in current workforce planning.

4.4. Additionally, it is important to factor into workforce planning that not all new SLTs will enter the NHS. Current planning risks not enough AHPs being trained to meet patient and system need, thereby increasing pressure on already overstretched services and exacerbating existing workforce pressures in the NHS. An accurate assessment of the needs of the entire system is crucial to understanding the true number of needed recruits to allied health professions.

4.5. Do the curriculums for training doctors, nurses, and allied health professionals need updating to ensure that staff have the right mix of skills?

4.6. At present, the curricula for speech and language therapy courses do not need an overhaul, but there are regular review and update schedules in place. UK-wide curriculum guidance for speech and language therapy courses was updated most recently in March 2021, and HEIs are expected to review the content of their programmes in line with current trends and updates.

5.0. What are the principal factors driving staff to leave the health and social care sectors and what could be done to address them?

5.1. Poor working conditions

5.2. A survey of RCSLT members’ wellbeing over the course of the COVID-19 pandemic[1] showed a steady increase in members reporting workplace stress, low morale at work, and difficulties arising from staff shortages. Furthermore, members were increasingly likely to describe their work environment as unpredictable, emotionally challenging, intense, overwhelming, stretching and relentless. This suggests that pressure is building on speech and language therapists to manage heavy workloads.

5.3. The demand placed on SLTs working in the NHS and the poor conditions in which they have to manage such demand may be contributing to SLTs leaving the NHS for more attractive conditions in the private sector.

5.4. Lack of CPD support to help with career progression

5.5. SLTs have reported increasing problems in access to CPD to support them in understanding the latest evidence base so that they can provide high quality care and meet the requirements set out by the regulator. Funding has been inequitable for some time and SLTs report this as a frequent issue, not only in terms of the cost of training, but also in terms of travel expenses to attend.

5.6. Additionally, time to attend training is an issue. Even when SLTs have the funding to access resources, the impact of pressures to see patients and manage waiting lists is resulting in reductions in SLTs being given time off for CPD.

5.7. Focus on waiting lists rather than patient outcomes

5.8. The opportunity to properly assess patients and make a meaningful intervention that focusses on the outcome for the patient is attractive to SLTs, but NHS commissioning based on processes rather than outcomes puts additional pressure on staff to simply meet a process target rather than focus on the best outcome for the patient. Ultimately this leads to less job satisfaction.

5.9. Demand outstripping supply across all settings

5.10. Recent evidence consistently indicates that community paediatric speech and language therapy services in England are unable to meet current demand. The Education Select Committee’s report, Special Educational Needs and Disabilities (2019) reported: “The lack of therapists is causing problems for local authorities in their assessment and review processes, schools for their ability to provide support for teachers and pupils, for the therapists themselves, and ultimately the children and young people who need their support.”

5.11. Paediatric services are not the only settings experiencing this rise in demand. In mental health settings, 60% of people have communication needs, and the number of people seeking mental health support is likely to increase following the impact of lockdown and the COVID-19 pandemic.

5.12. Furthermore, there is an increased 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.[2] 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.

5.13. In addition, more SLTs are needed to meet the requirements of the NHS England stroke service model, which increases demand by including 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. RCSLT has recommended one SLT per ten acute stroke beds, but many stroke units across the country are falling short of this level.

5.14. Reduction of leadership roles

5.15. SLTs want to see a visible career path that leads to senior roles. Cuts to senior clinical leadership posts, have not only created an increase in vacancies but also decreased the number of people able to supervise NQPs and offer placements or apprenticeships.

5.16. The reduction in band 8 AHP posts and the 23% decrease in SLT managers since 2010[3] in the NHS have led to smaller numbers of SLTs rising to leadership positions. In addition, AHPs are not routinely able to sit at Board level within ICSs. This restriction places a glass ceiling not present outside the NHS where it is possible for SLTs to progress in their careers. In the interests of equity and the development and delivery of services for patients, this needs to be removed.

6.0. Are there specific roles, and/or geographical locations, where recruitment and retention are a particular problem and what could be done to address this?

6.1. Our members report that there are increasing issues with recruiting SLTs to band 6 and 7 roles. The loss of international SLTs as a result of the COVID-19 pandemic has also increased such vacancies. See paragraphs 3.1-3.5 for more on international recruitment.

6.2. We understand that there are recruitment difficulties in London as well as in very rural geographic areas.

7.0. What should be in the next iteration of the NHS People Plan, and a people plan for the social care sector, to address the recruitment, training and retention of staff?

7.1. The NHS People Plan must ensure that enough staff are recruited, trained, and retained to ensure that children’s services can recover from the COVID-19 pandemic. 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.

7.2. Additionally, given the expansion of Integrated Care Systems, the NHS People Plan should ensure that every Integrated Care Board includes a Director who is an allied health professional, in the same way that they include Medical and Nursing Directors. As the third largest workforce in the NHS and as the clinicians working on the boundaries between health and social care, AHPs are crucial to delivering integration. They have a key role to play in delivering many of the ambitions of NHS England’s Long Term Plan. However, for that to happen, their experience and expertise – including both profession-specific knowledge and the broader AHP perspective – must be harnessed. If ICBs do not include AHPs, there is a risk that the totality of patients’ needs will not be adequately assessed and supported. This risks systemic decisions being skewed, taken without a full understanding of the impact on, and implications for, patients and the wider workforce.

7.3. Finally, it is vital that the next NHS People Plan includes recognition of the role of allied health professionals across health and social care, as well as in wider non-NHS settings. AHPs must see their roles valued and considered as part of the solution in order to improve staff retention.

8.0. To what extent are the contractual and employment models used in the health and social care sectors fit for the purpose of attracting, training, and retaining the right numbers of staff with the right skills?

8.1. The current contractual and employment models used in the health and social care sectors are slow to respond and embrace the needs of the workforce. Having more fluid lines of employment between HEIs and health and social care could support better career progression by contributing to recruitment, training, flexibility, retention, and overall job satisfaction for staff.

8.2. Furthermore, in order to recruit, train, and retain staff from all sectors, there must be some semblance of equity and potential flexibility between sectors – including non-health, voluntary, and independent.

8.3. The benefit of data must not be underestimated; until data about who is working where is available and robust, it will be challenging to understand, evaluate, and improve existing issues.

8.4. Recruitment

8.5. The precursor to recruitment is, of course, vacancies; however, the implementation of cost improvement programmes, where the view has historically been to reduce resourcing in areas where vacancies are carried, have led to susceptibility in the system particularly when the vacancy is due to need for a specialist skill mix, as is often the case for SLT.

8.6. A key issue in recruitment and retention is that of non-recurrent funding, which results in short-term contracts that either do not attract applicants or cause them to leave when a more permanent role becomes available.

8.7. Training

8.8. Funding training may be a challenging area depending on whether the budget is held centrally or devolved. In larger organisations, the decision regarding training spend may be based on organisational priorities rather than the skill mix required for face to face clinical care. In smaller organisations, although the relevant specialties and skill mixes may be prioritised, there is the challenge of a smaller budget to go round, which may lead to delays in offering funding for specialist courses. These two issues will undoubtedly impact on workforce retention.

8.9. Retention

8.10. A significant issue remains retention in the public sector, as most parts of the NHS have yet to catch up their organisational structures to match the most recent National Planning Guidance that places Health and Wellbeing of staff as the number one priority. There is an ever increasing interest in work-life balance for staff, in a way that was less evident prior to the COVID-19 pandemic.

8.11. Investigating the reasons why people are leaving NHS services – which may link to compassion in the workplace and feeling safe to ‘bring your whole self to work’ – is vital to understanding the increase of clinicians moving into independent practice and therefore improving staff retention.

9.0. What is the role of integrated care systems in ensuring that local health and care organisations attract and retain staff with the right mix of skills?

9.1. In order to ensure that AHPs hired have the right mix of skills, the interests of AHPs must be represented on Integrated Care Boards. See paragraph 7.2 for more on the importance of an AHP Director role on ICBs.

10.0. About the Royal College of Speech and Language Therapists

10.1. 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 over 19,000 SLT members. We promote excellence in practice and influence health, education, employment, social care and justice policies.

January 2022