Referral Patterns to Speech and Language Therapy in the UK before, during, and after the COVID-19 Pandemic: Dysphagia Compared with Communication Disorders.

INTRODUCTION: Acquired swallowing impairment is a major public health issue that often leads to increased morbidity and slower recovery. Speech and language therapists (SLTs) have taken the lead in the assessment and treatment of dysphagia, which is reflected in guidelines where early intervention is recommended. This is in addition to the central role that SLTs play in the management of acquired communication impairments since research indicates that patients with communication difficulties benefit from early and intensive therapy by SLTs. This increasing demand for SLTs is expected to cause conflicting pressures in their workload and, therefore, beneficial to consider workforce planning. The aim of this study was to examine real-world data in the UK to investigate this issue regarding changes in referral patterns of patients with dysphagia and/or communication disorders to SLTs over time, to assist with workforce planning. METHODS: We interrogated the Royal College of Speech and Language Therapists Online Outcome Tool, a national database, in this retrospective cohort study. We included patients evaluated between 2018 and 2022. We performed a subgroup analysis of patients aged ≥40 years who had a primary medical diagnosis of stroke. Data on age, primary diagnosis, time on caseload, primary Therapeutic Outcome Measure (TOM) scale and initial TOM score on impairment were examined. RESULTS: From the database of 44,444 referrals to speech and language therapy, 5,254 referrals were included in the stroke and overall subgroup analyses. Referrals were 55.1% male, with a median age of 71 years. More than half (56.1%) of these referrals were for dysphagia. Referrals decreased during the COVID-19 pandemic but began to recover from 2021 onwards. The time on the SLT caseload has increased over the years from a median of 14 days (interquartile range [IQR] 0-56) in 2018 to 20 days (IQR: 3-81) in 2022. While there were more referrals to SLT services for assessment and management of dysphagia than for communication in the overall population, in the stroke subgroup, referrals for communication disorders outnumbered referrals for dysphagia from 2020 onwards. Additionally, the severity of impairment on referral increased over the years. CONCLUSION: Real-world data indicates that referrals to SLT services are changing over time to include more complex and severely impaired patients, with a demand for both swallowing and communication disorders. These findings should inform staff allocation and remodelling of education/training for SLTs to better meet clinical and public health needs. The retrospective nature of this study limits the strength and generalisability of these data, and this topic warrants further investigation.

Giving voice to people with communication disabilities during mental capacity assessments.

BACKGROUND: Healthcare professionals without specialist training in communication disorders may not know how to identify and support patients with communication disabilities during mental capacity assessments. To meet this need, a novel communication screening tool was developed and tested as part of a mental capacity assessment support toolkit. AIMS: To provide an initial evaluation of the communication screening tool's usability, interrater reliability and criterion validity. METHODS & PROCEDURES: A prototype communication screening tool was developed iteratively using co-production and user-centred design principles. A mixed-methods case series design was used to explore how multidisciplinary healthcare professionals used the tool to test patients in acute hospital and intermediate care settings. Usability data were collected in an electronic survey and from a documentary analysis. Screening test outcomes obtained by pairs of professionals were compared to measure the tool's interrater reliability. Outcomes obtained by professionals were compared with the outcomes of a speech and language therapist's communication assessment to measure criterion validity. Quantitative data were analysed using frequency counts and inferential statistics. Qualitative data were analysed using framework analysis. OUTCOMES & RESULTS: A total of 21 professionals, including physicians, nurses, occupational therapists, physiotherapists, and speech and language therapists, and 17 patients with diagnoses of stroke or cognitive impairment took part. Professionals reported they found the tool easy to use, useful and that its use increased their understanding of communication support methods and the speech and language therapist role in relation to mental capacity assessment. However, not all used it consistently or accurately. Professionals reported they chose not to use the tool when they perceived patients' communication to be intact. Four of eight patients with a diagnosis of dementia or memory impairment, who professionals elected not to screen, were found to have significant communication needs. Screening outcome data for nine patients suggest the tool's interrater reliability is currently moderate, whilst its criterion validity is poor. CONCLUSIONS & IMPLICATIONS: This study highlights that non-speech and language therapist health professionals have difficulty identifying and screening for communication difficulties. This confirms existing evidence that people with communication disabilities may not receive the decision-making support they require during mental capacity assessments when speech and language therapists are not involved. Greater understanding of health professionals' thought processes regarding communication is required to further develop this unique communication screening tool so that it can effectively enable healthcare professionals to identify and use communicative adaptations to support decision-making. What this paper adds What is already known on this subject Limited previous research suggests that assessing the mental capacity of people with communication disabilities is complex. Practice needs to be improved to ensure this group is adequately supported to make decisions, in line with legal requirements. What this paper adds to existing knowledge This paper describes the development and testing of a novel communication screening tool for use by healthcare professionals preparing to undertake mental capacity assessments. It increases our understanding of how healthcare professionals without specialist training understand communication disability and the role of the speech and language therapist in relation to mental capacity assessment. What are the potential or actual clinical implications of this work? Healthcare professionals without specialist training require support to understand and respond to the needs of people with communication disabilities during mental capacity assessments. With further development and testing, in response to initial evaluation, this novel communication screening tool may be able to provide this support.

Speech, Language, and Communication in a Public Health Context: A UK Perspective with Potential Global Application - An Opinion Piece.

Speech and language therapists often contribute to public awareness campaigns as well as supporting, teaching and promoting the facilitation of speech, language, communication, and safe swallowing with the general public and health and social care professionals. These are sometimes considered as public health interventions. It is important to consider the objectives, costs, and impact of this involvement in the same way as reviewing the evidence associated with the more personally targeted interventions with individuals or groups of clients with specific conditions. This opinion piece discusses speech and language therapy in the context of public health, clarifies the terminology, and proposes different approaches to demonstrate its influence associated with its objectives. The content has been informed by a Working Party of the Royal College of Speech and Language Therapists (2017-2018).

Informing the Design of "Lifestyle Monitoring" Technology for the Detection of Health Deterioration in Long-Term Conditions: A Qualitative Study of People Living With Heart Failure.

BACKGROUND: Health technologies are being developed to help people living at home manage long-term conditions. One such technology is "lifestyle monitoring" (LM), a telecare technology based on the idea that home activities may be monitored unobtrusively via sensors to give an indication of changes in health-state. However, questions remain about LM technology: how home activities change when participants experience differing health-states; and how sensors might capture clinically important changes to inform timely interventions. OBJECTIVE: The objective of this paper was to report the findings of a study aimed at identifying changes in activity indicative of important changes in health in people with long-term conditions, particularly changes indicative of exacerbation, by exploring the relationship between home activities and health among people with heart failure (HF). We aimed to add to the knowledge base informing the development of home monitoring technologies designed to detect health deterioration in order to facilitate early intervention and avoid hospital admissions. METHODS: This qualitative study utilized semistructured interviews to explore everyday activities undertaken during the three health-states of HF: normal days, bad days, and exacerbations. Potential recruits were identified by specialist nurses and attendees at an HF support group. The sample was purposively selected to include a range of experience of living with HF. RESULTS: The sample comprised a total of 20 people with HF aged 50 years and above, and 11 spouses or partners of the individuals with HF. All resided in Northern England. Participant accounts revealed that home activities are in part shaped by the degree of intrusion from HF symptoms. During an exacerbation, participants undertook activities specifically to ease symptoms, and detailed activity changes were identified. Everyday activity was also influenced by a range of factors other than health. CONCLUSIONS: The study highlights the importance of careful development of LM technology to identify changes in activities that occur during clinically important changes in health. These detailed activity changes need to be considered by developers of LM sensors, platforms, and algorithms intended to detect early signs of deterioration. Results suggest that for LM to move forward, sensor set-up should be personalized to individual circumstances and targeted at individual health conditions. LM needs to take account of the uncertainties that arise from placing technology within the home, in order to inform sensor set-up and data interpretation. This targeted approach is likely to yield more clinically meaningful data and address some of the ethical issues of remote monitoring.

Prevalence of people who could benefit from augmentative and alternative communication (AAC) in the UK: determining the need.

BACKGROUND: Commissioners and providers require information relating to the number of people requiring a service in order to ensure provision is appropriate and equitable for the population they serve. There is little epidemiological evidence available regarding the prevalence of people who could benefit from augmentative and alternative communication (AAC) in the UK. AIM: To determine the prevalence of people who could benefit from AAC in the UK. METHODS & PROCEDURES: An epidemiological approach was taken to create a new estimate of need: the prevalence of the main medical conditions and specific symptoms leading to the requirement for AAC were identified from the literature and AAC specialists were consulted to estimate the number of people who may require AAC. OUTCOMES & RESULTS: A total of 97.8% of the total number of people who could benefit from AAC have nine medical conditions: dementia, Parkinson's disease, autism, learning disability, stroke, cerebral palsy, head injury, multiple sclerosis and motor neurone disease. The total expectation is that 536 people per 100 000 of the UK population (approximately 0.5%) could benefit from AAC. CONCLUSIONS & IMPLICATIONS: To provide accurate figures on the potential need for and use of AAC, data need to be consistently and accurately recorded and regularly reviewed at a community level. The existing data suggest an urgent need for more accurate and up to date information to be captured about the need for AAC in the UK to provide better services and ensure access to AAC strategies, equipment and support.

Implications of Untreated Cleft Palate in the Developing World: Adaptation of an Outcome Measure.

OBJECTIVES: To identify the implications of living with untreated cleft palate and develop an outcome measure which reflects the broad impact of surgery but is sensitive to the physical impact, speech changes, and psychosocial implications of late intervention. Design, Participants, Setting: Focus groups and individual interviews were used to gather information on the implications of living with untreated cleft palate and the impact of subsequent surgery. Participants included 11 individuals attending a cleft department in India whose cleft had persisted into adolescence or adulthood, as well as 16 of their family members. The findings were used to assess whether the Therapy Outcome Measure (TOM) could capture the implications of untreated cleft palate and the impact of surgery beyond that of speech alone. RESULTS: The findings indicated that the implications of living with untreated cleft palate revolved around difficulties with communication, reduced autonomy, and nasal regurgitation. These issues are encapsulated within the third and fourth domains of the TOM, but there is a need for an adapted version (TOM-clp) to use in the developing world, incorporating areas specific to cleft palate. CONCLUSION: The TOM has potential as a global tool for measuring the broad impact, including the psychosocial benefit, from attending to untreated cleft palate.

Assessing patient preferences for the delivery of different community-based models of care using a discrete choice experiment.

OBJECTIVES: To assess patient preferences for different models of care defined by location of care, frequency of care and principal carer within community-based health-care services for older people. DESIGN: Discrete choice experiment administered within a face-to-face interview. SETTING: An intermediate care service in a large city within the United Kingdom. PARTICIPANTS: The projected sample size was calculated to be 200; however, 77 patients were recruited to the study. The subjects had recently been discharged from hospital and were living at home and were receiving short-term care by a publicly funded intermediate care service. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The degree of preference, measured using single utility score, for individual service characteristics presented within a series of potential care packages. RESULTS: Location of care was the dominant service characteristics with care at home being the strongly stated preference when compared with outpatient care (0.003), hospital care (<0.001) and nursing home care (<0.001) relative to home care, although this was less pronounced among less sick patients. Additionally, the respondents indicated a dislike for very frequent care contacts. No particular type of professional carer background was universally preferred but, unsurprisingly, there was evidence that sick patients showed a preference for nurse-led care. CONCLUSIONS: Patients have clear preferences for the location for their care and were able to state preferences between different care packages when their ideal service was not available. Service providers can use this information to assess which models of care are most preferred within resource constraints.

Evaluation of the MCAST, a multidisciplinary toolkit to improve mental capacity assessment.

PURPOSE: To evaluate the usability and acceptability of the Mental Capacity Assessment Support Toolkit (MCAST) in healthcare settings and whether its use was associated with increased legal compliance and assessor confidence. MATERIALS AND METHODS: A mixed methods convergence triangulation model was used. Multidisciplinary professionals used the MCAST during mental capacity assessments for UK hospital patients with diagnoses of stroke or acute or chronic cognitive impairment. Changes in legal compliance were investigated by comparing scores on case note audits before and after implementation of the MCAST. Changes in assessor confidence and professionals' perceptions of the MCAST's usability and acceptability were explored using surveys. Patients' and family members' views on acceptability were determined using semi-structured interviews. Data were integrated using triangulation. RESULTS: Twenty-one professionals, 17 patients and two family members participated. Use of the MCAST was associated with significant increases in legal compliance and assessor confidence. Most professionals found the MCAST easy to use and beneficial to their practice and patients. Patients and family members found the MCAST materials acceptable. CONCLUSIONS: The MCAST is the first toolkit to support the needs of individuals with communication disabilities during mental capacity assessments. It enables assessors to deliver high quality, legally compliant and confident practice.IMPLICATIONS FOR REHABILITATIONMental capacity assessment practice needs to be improved to maximise patient autonomy, safety and well-being.The MCAST is a paper-based toolkit designed to facilitate and improve mental capacity practice in England and Wales.This study suggests the MCAST would be easy and acceptable to use in healthcare settings and could lead to improvements in assessment quality and assessor confidence.

Precision rehabilitation for aphasia by patient age, sex, aphasia severity, and time since stroke? A prespecified, systematic review-based, individual participant data, network, subgroup meta-analysis.

BACKGROUND: Stroke rehabilitation interventions are routinely personalized to address individuals' needs, goals, and challenges based on evidence from aggregated randomized controlled trials (RCT) data and meta-syntheses. Individual participant data (IPD) meta-analyses may better inform the development of precision rehabilitation approaches, quantifying treatment responses while adjusting for confounders and reducing ecological bias. AIM: We explored associations between speech and language therapy (SLT) interventions frequency (days/week), intensity (h/week), and dosage (total SLT-hours) and language outcomes for different age, sex, aphasia severity, and chronicity subgroups by undertaking prespecified subgroup network meta-analyses of the RELEASE database. METHODS: MEDLINE, EMBASE, and trial registrations were systematically searched (inception-Sept2015) for RCTs, including ⩾ 10 IPD on stroke-related aphasia. We extracted demographic, stroke, aphasia, SLT, and risk of bias data. Overall-language ability, auditory comprehension, and functional communication outcomes were standardized. A one-stage, random effects, network meta-analysis approach filtered IPD into a single optimal model, examining SLT regimen and language recovery from baseline to first post-intervention follow-up, adjusting for covariates identified a-priori. Data were dichotomized by age (⩽/> 65 years), aphasia severity (mild-moderate/ moderate-severe based on language outcomes' median value), chronicity (⩽/> 3 months), and sex subgroups. We reported estimates of means and 95% confidence intervals. Where relative variance was high (> 50%), results were reported for completeness. RESULTS: 959 IPD (25 RCTs) were analyzed. For working-age participants, greatest language gains from baseline occurred alongside moderate to high-intensity SLT (functional communication 3-to-4 h/week; overall-language and comprehension > 9 h/week); older participants' greatest gains occurred alongside low-intensity SLT (⩽ 2 h/week) except for auditory comprehension (> 9 h/week). For both age-groups, SLT-frequency and dosage associated with best language gains were similar. Participants ⩽ 3 months post-onset demonstrated greatest overall-language gains for SLT at low intensity/moderate dosage (⩽ 2 SLT-h/week; 20-to-50 h); for those > 3 months, post-stroke greatest gains were associated with moderate-intensity/high-dosage SLT (3-4 SLT-h/week; ⩾ 50 hours). For moderate-severe participants, 4 SLT-days/week conferred the greatest language gains across outcomes, with auditory comprehension gains only observed for ⩾ 4 SLT-days/week; mild-moderate participants' greatest functional communication gains were associated with similar frequency (⩾ 4 SLT-days/week) and greatest overall-language gains with higher frequency SLT (⩾ 6 days/weekly). Males' greatest gains were associated with SLT of moderate (functional communication; 3-to-4 h/weekly) or high intensity (overall-language and auditory comprehension; (> 9 h/weekly) compared to females for whom the greatest gains were associated with lower-intensity SLT (< 2 SLT-h/weekly). Consistencies across subgroups were also evident; greatest overall-language gains were associated with 20-to-50 SLT-h in total; auditory comprehension gains were generally observed when SLT > 9 h over ⩾ 4 days/week. CONCLUSIONS: We observed a treatment response in most subgroups' overall-language, auditory comprehension, and functional communication language gains. For some, the maximum treatment response varied in association with different SLT-frequency, intensity, and dosage. Where differences were observed, working-aged, chronic, mild-moderate, and male subgroups experienced their greatest language gains alongside high-frequency/intensity SLT. In contrast, older, moderate-severely impaired, and female subgroups within 3 months of aphasia onset made their greatest gains for lower-intensity SLT. The acceptability, clinical, and cost effectiveness of precision aphasia rehabilitation approaches based on age, sex, aphasia severity, and chronicity should be evaluated in future clinical RCTs.

"Riding the bumpy seas": or the impact of the Knowledge Skills Framework component of the Agenda for Change initiative on staff in intermediate care settings.

This paper explores the compatibility of the recently modernized NHS pay structure, "Agenda for Change" (AfC) with the workforce flexibilities arising within intermediate care services in the NHS in England. The findings reported here were an unanticipated outcome of a larger, Department of Health (England) study which explored the impact of workforce flexibility on the costs and outcomes of older peoples' community-based services. The research coincided with the introduction of AfC, and, as such pay modernization was a strongly emergent theme from focus groups that involved 11 teams as part of the larger study. In principle, it appears that both intermediate care and AfC should support the concepts of interprofessional working, blurring of role boundaries and role substitution, however the findings from this study suggest otherwise. In particular, intermediate care was described as a largely non-hierarchical service structure where staff roles expand horizontally to take on a broad plethora of generic tasks. In contrast, AfC promotes a hierarchical framework for career progression that recognizes and rewards defined skills, expertise and responsibility. From this perspective, AfC was seen to reward specialization rather than skill sharing, and had difficulty differentiating between and rewarding staff with broad generalist roles.

How do health and social care professionals in England and Wales assess mental capacity? A literature review.

Purpose: To review evidence describing how health and social care professionals in England and Wales assess mental capacity, in order to identify ways to improve practice.Methods: A systematised literature review was completed. Electronic databases of published medical, health and social care research and gray literature were searched. Journal articles and research reports published between 2007 and 2018 were included if they met predefined eligibility criteria. Evidence from included studies was synthesized using thematic analysis.Results: 20 studies of variable methodological quality were included. The studies described assessments carried out by a range of multidisciplinary professionals working with different groups of service users in diverse care contexts. Four main themes were identified: preparation for assessment; capacity assessment processes; supported decision-making; interventions to facilitate or improve practice. There was a lack of detailed information describing how professionals provided information to service users and tested their decision-making abilities. Practice reported in studies varied in terms of its conformity to legal requirements.Conclusions: This review synthesized evidence about mental capacity assessment methods and quality in England and Wales and analyzed it to suggest ways in which practice might be improved.Implications for rehabilitationMental capacity assessment practice in England and Wales varies and is not always consistent with legal requirements, risking inconsistent and inaccurate judgements about capacity and exposure to legal action.Interventions have been developed to help professionals to engage in supported decision-making, and improve their mental capacity assessments and documentation in line with legal standards.These interventions include training and practical resources, such as assessment flowcharts, checklists and documentation aids. Such interventions would benefit from robust evaluation before they are implemented more widely.

Outcome measurement in speech and language therapy: a digital journey.

BACKGROUND: Evidencing the impact of speech and language therapy interventions is challenging. The UK's professional body for speech and language therapists (SLTs) is supporting a consistent approach to outcome measurement and analysis using Therapy Outcome Measures (TOMs). OBJECTIVE: To develop a digital solution for collecting TOMs data, evaluate the impact of therapeutic interventions and explore contributing factors to outcome variation across clinical areas. METHOD: Agile methodology was applied to software development. Organisations were recruited to provide data. Criteria were identified to exemplify outcome variability. RESULTS: A digital tool was developed. 21 organisations provided data on 16 356 individuals. Improvement in at least one domain of TOMs occurred in 77.1% of instances. Data for two clinical areas exemplify the tool's effectiveness in highlighting the impact of speech and language therapy. CONCLUSION: This established outcomes data set can be used to evaluate the impact of speech and language therapy, and explore variation in outcomes.

RELEASE: a protocol for a systematic review based, individual participant data, meta- and network meta-analysis, of complex speech-language therapy interventions for stroke-related aphasia.

Background: Speech and language therapy (SLT) benefits people with aphasia following stroke. Group level summary statistics from randomised controlled trials hinder exploration of highly complex SLT interventions and a clinically relevant heterogeneous population. Creating a database of individual participant data (IPD) for people with aphasia aims to allow exploration of individual and therapy-related predictors of recovery and prognosis. Aim: To explore the contribution that individual participant characteristics (including stroke and aphasia profiles) and SLT intervention components make to language recovery following stroke. Methods and procedures: We will identify eligible IPD datasets (including randomised controlled trials, non-randomised comparison studies, observational studies and registries) and invite their contribution to the database. Where possible, we will use meta- and network meta-analysis to explore language performance after stroke and predictors of recovery as it relates to participants who had no SLT, historical SLT or SLT in the primary research study. We will also examine the components of effective SLT interventions. Outcomes and results: Outcomes include changes in measures of functional communication, overall severity of language impairment, auditory comprehension, spoken language (including naming), reading and writing from baseline. Data captured on assessment tools will be collated and transformed to a standardised measure for each of the outcome domains. Conclusion: Our planned systematic-review-based IPD meta- and network meta-analysis is a large scale, international, multidisciplinary and methodologically complex endeavour. It will enable hypotheses to be generated and tested to optimise and inform development of interventions for people with aphasia after stroke. Systematic review registration: The protocol has been registered at the International Prospective Register of Systematic Reviews (PROSPERO; registration number: CRD42018110947).

Looking inside the black box of community rehabilitation and intermediate care teams in the United Kingdom: an audit of service and staffing.

OBJECTIVE: To generate a picture of the range, configuration and staffing of community and intermediate care services in the United Kingdom (UK) and to ascertain whether any relationships exist between service configuration and staffing models. METHOD: A service audit tool was sent to members of the Community Therapist's Network (CTN) and to chief executives of primary care and National Health Service trusts in the UK. Data were collected from the CTN and chief executives of primary care trusts (PCTs) and NHS trusts between late 2005 and early 2006. RESULTS: The overall response rate to the two audits was 37% (n = 243), with 77% of these responses (n = 186) useable. Services varied greatly in terms of their organisation and staffing configurations. Skill mix varied according to the location of service delivery, with home-based services utilising more therapy and support staff than inpatient services. Two clusters of service emerged, based on the number of referrals per year, support staff in the team and the level of care provided by the service. CONCLUSION: There are no clear patterns to the structure and organisation of community and intermediate care services in relation to their purpose, and it remains unclear how different staffing configurations impact on service costs and patient outcomes. The amount of variation observed indicates that there is likely to be considerable variability in service costs and outcomes for the teams. Further evidence is required to determine the impact of different staffing models, and to identify approaches that optimise both effectiveness and efficiency.

An exploration of mental capacity assessment within acute hospital and intermediate care settings in England: a focus group study.

PURPOSE: To explore approaches to the assessment of mental capacity within acute hospital and intermediate care settings in England. METHODS: Two focus group interviews were conducted with multidisciplinary staff (n = 13) within a large hospital trust. Data were analysed using a Framework approach. RESULTS: Three main themes were identified: (i) the assessment process; (ii) staff experience of assessment; (iii) assessing capacity for patients with communication difficulties. Staff identified the main patient groups, patient decisions and professionals involved in capacity assessment. They described using both formal and informal approaches to assess capacity and specific methods to identify and support the needs of patients with communication difficulties during the assessment process. Most staff reported finding capacity assessment challenging, due to time pressures, a perceived lack of knowledge or skills and encountering practice that is not consistent with legal requirements. Staff stated a need for initiatives to facilitate and improve practice. CONCLUSIONS: These findings provide confirmatory evidence that mental capacity assessment is complex and challenging and that staff would benefit from additional support and resources to aid their practice. It provides new evidence about the methods used by staff to assess capacity, particularly for patients with communication difficulties. Implications for Rehabilitation This study contributes to our understanding of how staff assess capacity in hospital and intermediate care settings. Mental capacity assessment is a complex activity and many staff reported finding it challenging. Patients with communication difficulties need additional support during capacity assessments but may not always receive this. Current practice needs to be improved and staff need support and resources to achieve this.

Stakeholder views of the training needs of an interprofessional practitioner who works with older people.

This paper, reports on United Kingdom research to examine the education and training requirements of an interprofessional practitioner for older people. The research was part of a larger study, funded by a local Workforce Development Confederation to identify whether there is a need for an interprofessional practitioner, and if so, determine their role and training requirements. Views of clients, carers and service providers were elicited using multiple methods including interviews, focus groups and questionnaires. The majority of service providers identified the need for an interprofessional practitioner and confirmed that these staff already exist within many multi-disciplinary community teams. The range of educational needs identified reflects the understanding that rehabilitation for older people requires a broad spectrum of knowledge and skills that cover both 'health' and 'social' needs. It was felt that education and training should be established and accredited at a national level, with a career structure and appropriate recognition of the interprofessional role. Clients and carers identified unmet needs and want a 'Jack of all trades' who will complement the existing workforce. They recommended that recognised qualifications would provide interprofessional workers with 'status' and therefore acceptance by other professionals. This paper, discusses the implications of the stakeholder views on interprofessional education and training.

Non-pharmacological treatments for stuttering in children and adults: a systematic review and evaluation of clinical effectiveness, and exploration of barriers to successful outcomes.

BACKGROUND: Despite many years of research, there is no certainty regarding the cause of stuttering. Although numerous interventions have been developed, a broad-based systematic review across all forms of intervention for adults and children was needed including views and perceptions of people who stutter. OBJECTIVE: The aims of the study were to report the clinical effectiveness of interventions for people who stutter (or clutter), to examine evidence regarding the views of people who stutter and the views of professionals regarding interventions. DATA SOURCES: A systematic review of quantitative and qualitative literature was carried out between August 2013 and April 2014. The following electronic databases were searched: (1) MEDLINE, (2) EMBASE, (3) The Cochrane Library (including The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, Health Technology Assessment Database and NHS Economic Evaluations Database), (4) PsycINFO, (5) Science Citation Index, (6) Social Science Citation Index, (7) Cumulative Index to Nursing and Allied Health Literature, (8) ASSIA, (9) Linguistics and Language Behavior Abstracts, (10) Sociological Abstracts and (11) the EPPI Centre. Reference lists of included papers and other reviews were screened and also key journals in the subject area were hand-searched. REVIEW METHODS: The searches aimed to identify (1) evidence of clinical effectiveness in populations of pre-school children, school-aged children, adolescents and adults, and (2) data relating to perceptions of barriers and facilitators to intervention clinical effectiveness among staff and people who stutter. A metasynthesis of the two linked elements via development of a conceptual model was also carried out to provide further interpretation of the review findings. RESULTS: A systematic search of the literature identified a large number of potentially relevant studies. Of these, 111 studies examining the clinical effectiveness of interventions, 25 qualitative papers and one mixed-methods paper met the criteria for inclusion in this review. Review of the effectiveness literature indicated evidence of positive outcomes across all types of interventions. Virtually all evidence we identified reported at least some positive effect for some participants. However, there was evidence of considerable individual variation in outcome for study participants. The qualitative literature highlighted the need for programmes to be tailored to individual need with variation at the levels of the intervention, the individual and interpersonal/social elements. Metasynthesis of the data highlighted the complexity of elements that need to be considered in evaluation of long-term impacts following stuttering interventions. LIMITATIONS: Around two-thirds of the studies were considered to be at higher risk of bias. The heterogeneous nature and variability in outcomes meant that we were unable to complete a meta-analysis. CONCLUSIONS: Although much of the evidence we identified was from studies at risk of bias, it is suggested that most available interventions for stuttering may be of benefit to at least some people who stutter. There is a requirement for greater clarity regarding what the core outcomes following stuttering intervention should be and also enhanced understanding of the process whereby interventions effect change. Further analysis of those for whom interventions have not produced a significant benefit may provide additional insights into the complex intervention-outcomes pathway. STUDY REGISTRATION: This study is registered as PROSPERO CRD42013004861.

Comparing outcomes of voice therapy: a benchmarking study using the therapy outcome measure.

The quality cycle requires clinicians to assess the outcomes of interventions. Benchmarking is an approach that has been advocated to compare current performance across different services to identify commonalities and significant differences. This article gives the results of a study of outcomes in speech and language therapy (SLT) using the therapy outcome measure (TOM) for patients with voice disorder (dysphonia) comparing outcomes of seven separate speech and language therapy services. The study aimed to identify the similarities and differences in outcomes of care provided by different services. Two hundred and forty patients with dysphonia (age range 3-87.5 years, average 51.9 years) were treated. The results indicated that although there was no significant difference in the profile of the severity of symptomology of patients referred to speech and language therapy in different geographical areas, there was a significant difference in the treatment outcomes across the services and in the stated reason for discharge from treatment. Nevertheless, most patients with dysphonia had a good outcome and this was associated with completion of the course of treatment. There were significant differences in the number of treatment contacts provided by the different services and in the duration (between admission and discharge) of treatment across the services. Benchmarking can provide useful information through use of routinely collected clinical data.

Mechanisms to enhance the effectiveness of allied health and social care assistants in community-based rehabilitation services: a qualitative study.

This research aims to describe the factors associated with successful employment of allied health and social care assistants in community-based rehabilitation services (CBRS) in England. The research involved the thematic analysis of interviews and focus groups with 153 professionally qualified and assistant staff from 11 older people's interdisciplinary community rehabilitation teams. Data were collected between November 2006 and December 2008. Assistants were perceived as a focal point for care delivery and conduits for enabling a service to achieve goals within interdisciplinary team structures. Nine mechanisms were identified that promoted the successful employment of assistants: (i) Multidisciplinary team input into assistant training and support; (ii) Ensuring the timely assessment of clients by qualified staff; (iii) Establishing clear communication structures between qualified and assistant staff; (iv) Co-location of teams to promote communication and skill sharing; (v) Removing barriers that prevent staff working to their full scope of practice; (vi) Facilitating role flexibility of assistants, while upholding the principles of reablement; (vii) Allowing sufficient time for client-staff interaction; (viii) Ensuring an appropriate ratio of assistant to qualified staff to enable sufficient training and supervision of assistants; and (ix) Appropriately, resourcing the role for training and reimbursement to reflect responsibility. We conclude that upholding these mechanisms may help to optimise the efficiency and productivity of assistant and professionally qualified staff in CBRS.