SERVICE REDESIGN

Building pyramids on Planet Zog

A paediatric speech and language therapy service based in local communities and offering equitable provision appropriate to clinical need may sound like the stuff of science fiction but, as our superheroes Nikki Joyce and Jan Broomfield relate, with careful planning it is well within our orbit.
READ THIS IF YOUR SERVICE HAS PROBLEMS WITH NONATTENDANCE LACKS EQUITY NEEDS A CHANGE e are great believers in spotting any potential challenges on the horizon and proactively seeking means and methods of addressing them before they come fully to fruition, or before someone else comes along and decides on our agenda. When we set out to discuss the governments recent papers and the challenges that Childrens Centres would bring to our paediatric service, we never suspected that a wholesale reorganisation would emerge or indeed that the enthusiasm and motivation from each and every member of the team would mean that our initial thoughts of a three to five year plan would turn into an almost overnight revolution

A. THE SERVICE
Middlesbrough Primary Care Trust provides speech and language therapy services for children in the Middlesbrough and Redcar Cleveland areas in the North East of England. (The speech and language therapy service for adult neurological / acquired disorders is provided by South Tees Acute Trust.) The population is in the region of 300,000 and there are 4,000 new births each year. The locality has nine Sure Start projects that are developing into fourteen Childrens Centres, and four wards fall into the top ten most deprived in the UK (www.statistics.gov.uk). Much of the population resides in urban areas, but there is a proportion of rural and farming communities. The service had a paediatric department (catering for mainstream clinical work as well as language units / resource bases and assessment classes / support bases in mainstream schools), a Sure Start department covering all nine projects, and a special needs department (including children with learning disability, physical disability, hearing impairment and autistic spectrum disorders). There are 22.4 whole-time equivalent (wte) speech and language therapists and 12.5 wte speech and language therapy assistants supported by 4.2 wte administrative staff. Children aged 0 to 4 years living within Sure Start areas received therapy in homes, Sure Start Centres and local nurseries. All other mainstream children received therapy at one of three community clinics sited across the patch; so children from around 100 schools in an area spanning 50 by 10 miles were travelling for anything up to an hour each way to attend therapy. Needless to say, non-attendance was an issue. Children with

special needs attend specialist pre-school and educational provision, where therapy is provided. A number of factors led us to consider a full restructuring of the service, including: 1. The National Service Framework for children, young people and maternity services (DH, 2004) and Every Child Matters (www.everychildmatters.gov.uk) 2. The Primary Care Trust move to locality working for Public Health teams 3. Evidence from the KITE randomised controlled trial (Broomfield, 2005) 4. Concern about ongoing non-attendance at community clinic appointments 5. Concern about time lost from schooling when children did attend 6. Feedback from parents indicating they wished to have more accessible services 7. Feedback from education professionals having experienced better joint working and improved liaison from Sure Start speech and language therapy teams 8. Transition from Sure Start to Childrens Centres 9. Feedback from our own staff about the benefits of working within Sure Start teams and within localities.

B. THE PROCESS
A planning week was set aside in October 2004, where all senior speech and language therapy staff met to conduct a SWOT (Strengths, Weaknesses, Opportunities, Threats) analysis on current provision, determine what our ideal service provision would be, and identify an implementation plan. All staff in the service were involved on the first day, identifying their wishes and concerns as well as ideas and expectations, to inform the process. We

Photos show zone teams as they head off on a team-building treasure hunt. Below left to right: East zone, Central zone, South zone, East Cleveland zone, North zone, Eston zone,Redcar zone.

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SERVICE REDESIGN

had no external facilitator, identifying that two key members of the management team were better placed to take on this role. A crucial element was that each day ended with the setting of the agenda for the following day. The timetable for the week was: Monday am All staff involved: Presentation by representatives from the two Local Authorities on Childrens Centres Presentation from speech and language therapy management team about aims and objectives for the week Brainstorming session for all staff to identify their wishes and concerns, ideas and expectations Senior staff: Current facts and figures about the population and caseloads Collation of evidence and policies Decision to move to locality working Blue sky thinking what would the service look like if we were starting from scratch without any resource or policy restrictions Determining the key elements of the service delivery model Adding detail to the model who would do what to whom Identifying the action plan Timescale for implementation Plan for consultation with key stakeholders Primary Care Trust, Local Authorities including Education, parents, Sure Start managers Preparation of a presentation for all staff Full staff meeting to reveal the proposed model

1. Children (figure 2) The base level addressed all children regardless of any communication need, the middle level addressed all children with communication delay, and the top level addressed all communication disordered children. 2. Service (figure 3) The base level addressed the nature of the locality teams, the middle level addressed management of children with communication delay, and the top level addressed specialist speech and language therapists within the service. 3. Delivery (figure 4) The base level addressed health promotion and prevention work, the middle level addressed assessment, training and consultation, and the top level addressed specific speech and language therapy intervention. 4. Location (figure 5) The base level incorporated working within the childs locality, the middle level incorporated structured settings accessed by the child, and the top level addressed specific speech and language therapy locations.

Figure 1 The four elements

Children

Service

Delivery

Location

Figure 2 Children

Disordered Delayed / different All children aged 0 - 16

Figure 3 Service

Monday pm

Specialist team
Input from core team, MDT and parents

Others
Responsibility with SLTA, nursery, school Input from SLT, specialist team as required

Tuesday

Core Team

D. IMPLEMENTATION
Between October 2004 and September 2005, we integrated our Sure Start and mainstream paediatric speech and language therapy staff and reorganised into seven locality teams which matched the developing Public Health teams and the Local Authority Education clusters. Each Core Speech and Language Therapy Team consists of a team lead (a senior / specialist therapist), together with generalist speech and language therapists, speech and language therapy assistants and administration and clerical sessions. In addition, each specialist therapist is attached to a core team, and each team has allocated time and support from a designated member of the speech and language therapy management team. Each team has been relocated to a base within their locality and has responsibility for the whole child population therein. Each core team is responsible for a. Caseload management assessment and intervention in homes, nurseries and schools within their locality b. Training and liaison with education colleagues c. Screening, including conducting Sure Start Language Measures d. Health promotion activities, linked with health visitors and Childrens Centres e. Gathering feedback and evaluating their practice f. Onward referral and identification of children requiring specialist input g. Implementing care plans according to departmental care pathways

Input from specialist team, MDT, parents as required

Figure 4 Delivery

Wednesday Thursday Friday

Specific
Input specific to disorder From specialist team Assessments, training, diagnostic therapy Support offered to core team

Focused
Input focused on communication Input and monitoring by others SLTA doing specialist intervention Training by SLT service Assessment by core team SLT Core team SLT involved with at risk families

Holistic
2 Year screening by core team SLT Health promotion Prevention Training Environmental enrichment

Tuesday

Figure 5 Location

C. THE MODEL
There were four major elements of the new service delivery model (figure 1): 1. the caseload, including the Health Promotion aspect of Sure Start Children 2. the staffing Service 3. what we were going to do Delivery, 4. where we were going to do it Location. Each element, based on thetriangle of need, formed a side of a four-sided pyramid, and each element had three tiers.

SLT specific locations

Used for low incidence disorders and located according to prevalence

Community of childs residence

Health settings, schools, nurseries, homes

Everywhere
All locations that the child and family may access

SPEECH & LANGUAGE THERAPY IN PRACTICE Autumn 2007

SERVICE REDESIGN

h. Ensuring equity of speech and language therapy provision across the whole patch, whilst meeting local need. We have a number of specialist therapists, covering specific language impairment, specific speech disorder, dysfluency, ENT and cleft lip and palate, autism spectrum disorder, learning disability, physical disability and AAC, hearing impairment and dysphagia. Each specialist is responsible for: i. Specialist diagnostic assessment and intervention ii. Providing advice and support to all core teams iii. Operating surgery time for core teams, including conducting visits and directing therapy iv. Reviewing and developing specific care pathways v. Providing training to colleagues both within and outwith the service vi. Conducting evaluation and appraisal of best current evidence base vii. Working together with the management team to continuously evaluate and develop the service. The speech and language therapy management team is responsible for the operational management and straFigure 6 In practice

tegic direction of the service. It comprises five Clinical Co-ordinators, a Consultant speech and language therapist and a Professional Lead. Each person has a clinical specialism and acts in a specialist capacity. In addition, the Clinical Co-ordinators have specific management responsibilities representing the whole service, such as child protection, clinical supervision and audit. The Consultant has responsibility for research and development and facilitating evidence based practice. The Professional Lead has responsibility for staff and financial management. The two case examples in figure 6 show how the model is working in practice.

E. OUTCOMES
We have recently consulted a range of parents to obtain feedback about our reconfigured service. All responses were extremely positive; in particular, they liked Children being seen in schools and nurseries, as they know the setting and they dont need to travel Less time being lost from the curriculum The same small team stays involved throughout The service is flexible to meet the needs of families and children They see speech and language therapists and teaching staff talking to each other They still have the opportunity to attend their childs appointments They get termly (at least) updates by phone or post about their childs progress; they also still get homework packs to practise They like seeing speech and language therapists at Childrens Centre activities, so they can chat informally about concerns without having to have been properly referred. We are in the process of conducting a formal evaluation with our education and health colleagues. However, comments about the following issues have been made informally to us from both inside and outside the service: Better access to speech and language therapists by teaching staff - and of teachers by speech and language therapy staff - to get advice, ask questions, and discuss kids were worried about Fewer inappropriate referrals Better attendance at appointments, so therapy is more effective The service is far more flexible and responsive to client and school need Children hardly miss any class time now Cycle of discharge and re-referral has all but ceased children are maintained on the active caseload throughout their pre-school years (at least) Referrals now made of harder to reach families who wouldnt have attended central clinic but do (usually) attend school Increased contact with health visitors, maternity staff and Childrens Centre teams has increased referrals of very young children, often with complex needs. This has led to earlier access to the child development centre, earlier multidisciplinary team assessment, earlier diagnosis and appropriate support in place when the child starts school. Sure Start health promotion activities are being rolled out across the patch Multidisciplinary / multi-agency working is becoming a reality. In terms of facts and figures, referrals have doubled in the space of a year from 289 in Jan-June 2005 to 540 in Jan-June 2006, with fewer inappropriate referrals being received. The total active caseload is 2843. The active caseload in each zone is between 226 and 312, and the active caseload managed by specialists is between 25 and 169. Non-attendance has dropped from 780 in the year 02-03 to 360 in 05-06. Feedback from referrers is that they are now more aware of who we are, where we are and what we do and therefore they are more likely to refer. They are also more confident that the child will access the service as we are based in schools and the community. The implications of this for the service are that some of the preventative Sure Start activi-

Connor was seen at home by a speech and language therapy assistant for a Sure Start Language Measure at 2 years old. At that time he had an expressive vocabulary of 30 single words and the assistant encouraged his mum to attend the Sure Start Parent and Toddler Group. The assistant visits the group each month. When on the next visit mum expressed concerns about Connors feeding, the assistant supported mum in making a formal referral to the speech and language therapy service. Connor was assessed at 30 months by the core team speech and language therapist who felt that he would benefit from assessment by the dysphagia specialist. The dysphagia specialist therapist offered a joint assessment appointment with the core team therapist at the Parent and Toddler Group. Guidance for management of the difficulty was given to both mum and the core team. During the next three months, the core team therapist became increasingly concerned about Connors developmental milestones and referred him to the specialist pre-school assessment provision. Multidisciplinary assessment identified moderate global delay with specific communication difficulties. He was given a place in the local Childrens Centre nursery where his difficulties could be addressed. The core team will continue to support the nursery and mum to maximise his communication potential.

Sarah was referred for speech and language therapy assessment by her nursery teacher. She was assessed at 3 years 9 months in nursery by the core team therapist who identified significant speech difficulties. Sarah was then placed in an early speech skills group with her peers, run by the speech and language therapy assistant in her nursery. After half a term, at 4 years, Sarah was still very difficult to understand and all involved were expressing concern. The specialist therapist was consulted and it was agreed that Sarah should receive a period of diagnostic assessment. She was grouped with three similar children from the locality and the intervention was delivered in a local Childrens Centre location by the specialist therapist supported by a speech and language therapy assistant from the zone. Sarah was identified as presenting with inconsistent deviant phonological disorder. A period of intervention following the Core Vocabulary approach (Dodd et al., 2006) then occurred; this was run weekly in nursery by the specialist therapist, with both the zone therapist (for the purposes of training) and a zone assistant present. The zone assistant then conducted a second weekly practice session at home in order to keep mum involved. After a term of input, Sarah had made good progress and was recently jointly re-assessed by the zone and specialist therapists. Her next period of intervention focusing on specific sound targets has been planned jointly and is being implemented by the speech and language therapy assistant; weekly support is available from the zone therapist and monthly update discussions with the specialist are planned.

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SERVICE REDESIGN / RECOMMENDED READING

ties have reduced to increase time for direct intervention. We have also become smarter about putting children on review. Because we are more accessible and have provided training into schools, education colleagues are more comfortable with monitoring the children and rereferring and we provide them with clear guidelines as to what to look for and when to re-refer. This helps to keep the numbers manageable.

Recommended Reading
Given the overwhelming amount of information available, we need to be selective in what we read. Even then we find that papers do not always include an explicit link between the theory / experiment and its direct or indirect implications for practice. Articles in journals have gone through a painstaking process of peer review but it is ultimately for you, the reader, to judge whether the stated result is a) valid and b) clinically important in other words, why and how the article will change your practice. In this occasional section, readers explain why they would recommend a particular article from a peer reviewed journal to their colleagues. While this is a personal response that focuses on clinical importance and practicalities, the author may also wish to comment on factors such as study design / validity and statistics / statistical significance. VOICE / CHRONIC COUGH Vertigan, A.E., Theodoros, D.G., Gibson, P.G. & Winkworth, A.L. (2006) Efficacy of speech pathology management for chronic cough: a randomised placebo controlled trial of treatment efficacy, Thorax, December 61, pp. 1065 - 1069. [Available via www.thorax.bmj.com.] Jane Armstrong says: This article about treatment efficacy for chronic cough was emailed to me by my referring ENT Consultant. In our current climate of everything being evidence based it is nice to see an article which shouts the virtues of speech and language therapy in the area of voice and cough management. For those of us who work with voice and / or cough, this article is a welcome sight. There are four components to Vertigan et al.s treatment method for chronic cough: 1. Education 2. Strategies to reduce cough 3. Reduce laryngeal irritation / improve vocal hygiene 4. Psycho-educational counselling

F. NEXT STEPS
The formal evaluation is just beginning this will be an ongoing process and will influence future modifications to the service. However, we have a few outstanding matters to be addressed: 1. We need to consider the issue of ensuring parents are fully engaged when children are seen in school 2. At present, much of the restructure has focused on the mainstream element of the service, although the special needs specialists have been involved through surgery time and the inclusion agenda. However, a full review of the special needs speech and language therapy service is planned during 2007 3. The broader issue of mainstreaming the Sure Start budget and securing funding for the service developments we have identified as a result of being more accessible is on the agenda, but we hope that our integrated model will have put us on a sounder footing. Our stakeholders have been extremely supportive of the reorganisation to date which can only be to the good. We are hugely grateful to the Primary Care Trust boards and the Local Education Authority officers for their support and enthusiasm, and for sharing the vision with us. We are grateful to all the parents who contributed to our thinking through various feedback mechanisms before, during and after the reorganisation. And we are indebted to every single member of staff, whether therapist, assistant or administrative officer, for the initial drive and the ongoing commitment to building pyramids on Planet Zog! Nikki Joyce is Professional Lead and Jan Broomfield is Consultant Speech and Language Therapist for the Childrens Speech and Language Therapy Service of Middlesbrough Primary Care Trust. For further information please contact them at jan.broomfield@nhs.net

References
Broomfield, J. (2005) The case for flying KITEs, Speech & Language Therapy in Practice Winter, pp. 14-17. Great Britain. Department of Health, Department for Education and Skills (2004) National Service Framework for children, young people and maternity services. London: The Stationery Office. [Online at www.dh.gov.uk] Dodd, B., Holm, A., Crosbie, S. & McIntosh, B. (2006) A core vocabulary approach for management of inconsistent speech disorder, Advances in Speech-Language Pathology 8(3), pp. 220-230. SLTP *Planet Zog is a place or situation far removed from what is curREFLECTIONS rently happening, and a general name for any sci-fi planet.

DO WE THINK AHEAD SO WE CAN FORGE OUR OWN PATH OR DO WE WAIT FOR OTHERS TO DECIDE IT FOR US? DO WE GIVE SERVICE REDESIGN THE PLANNING TIME AND ATTENTION TO DETAIL THAT IT NEEDS? DO WE LISTEN TO WHAT CLIENTS, STAFF AND THE WIDER TEAM SAY WORKS BEST?

The placebo group got a course on healthy lifestyle education which included relaxation, stress management, exercise and diet. Both groups attended four intervention sessions with a qualified speech and language therapist. 1. Education Ideas: No physiological benefit from cough Capacity for voluntary cough control Futility of repeated coughing Negative side effects of repeated coughing Benefits of cough suppression 2. Cough suppression Ideas: Anticipate when a cough was about to occur Pattern and degree of warning before the cough Implement a strategy to suppress or replace the cough 3. Vocal Hygiene Ideas: Reduce laryngeal irritation Maximise hydration in order to reduce stimulation of cough receptors Relaxed breathing exercises provided for those with inspiratory dyspnoea 4. Psycho-educational Ideas: Address some differences between behavioural and medical treatment Aim to facilitate acceptance of a behavioural approach Facilitate internalisation of control over their cough View the cough as something individuals do in response to irritating stimuli rather than a phenomenon outside of their control. This approach is designed to reduce the load on the larynx by improving the efficiency of voicing and promoting adequate breath support and oral resonance. Lots of home practice was encouraged. The results show a significant improvement in those people who were receiving the treatment rather than the placebo. And to quote from the article, in conclusion, clinical judgement and symptom ratings support the hypothesis that speech pathology treatment is an effective behavioural intervention for chronic cough which could be considered a valid alternative for individuals whose cough persists despite medical intervention. Jane Armstrong is an independent speech and language therapist in Edinburgh.

SPEECH & LANGUAGE THERAPY IN PRACTICE Autumn 2007

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